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Full text of "An independent review of the Work Capability Assessment - year two"

An Independent Review 
of the Work Capability 
Assessment - year two 



Professor Malcolm Harrington 



November 2011 



An Independent Review 
of the Work Capability 
Assessment - year two 

Professor Malcolm Harrington 

November 2011 



Presented to Parliament pursuant to Section 10 

of the Welfare Reform Act 2007 

London: The Stationery Office £20.50 



© Crown Copyright 2011 

You may re-use this information (excluding logos) free of charge in any format or 
medium, under the terms of the Open Government Licence. To view this licence, 
visit http://www.nationalarchives.gov.uk/doc/open-government-licence/ or e-mail: 
psi@nationalarchives.gsi.gov.uk 

Where we have identified any third party copyright information you will need to 
obtain permission from the copyright holders concerned. 

This publication can be accessed online at: www.dwp.gov.uk/wca-review 

For more information about this publication, contact: 

WCA Independent Review Team 

Department for Work and Pensions 

2nd Floor 

Caxton House 

Tothill Street 

London, SW1H9NA 

E-mail: wca.evidence@dwp.gsi.gov.uk 

Copies of this publication can be made available in alternative formats if required. 

This publication is also available on http://www.official-documents.gov.uk/ 

ISBN: 9780108511103 

Printed in the UK by The Stationery Office Limited 

on behalf of the Controller of Her Majesty's Stationery Office 

ID 2463701 11/11 

Printed on paper containing 75% recycled fibre content minimum. 



An Independent Review of the Work Capability Assessment - year two 

Contents 

Foreword 5 

Executive Summary 17 

Chapter 1 : The Review outline 1 1 

Chapter 2: Implementation of the year one recommendations 1 7 

Chapter 3: Descriptors 29 

Mental health descriptors 30 

Fluctuating conditions descriptors 33 

Cancer treatment 34 

Real world test 37 

Chapter 4: Research 43 

i) Quality decision making 43 

ii) Withdrawn claims 45 

Chapter 5: Atos Healthcare 47 

i) Logic Integrated Medical Assessment (LiMA) 47 

ii) Consistency of Atos healthcare professional performance 55 

iii) Call for Evidence responses 61 

Chapter 6: Training 65 

Chapter 7: Other issues 71 

People who are found Fit for Work but are unable to claim 

Jobseeker's Allowance 71 

Complex problems and chaotic lifestyles 74 

Communication problems, including dyslexia 76 

Northern Ireland Independent Review 77 

Conclusion 81 

Annex A: List of recommendations 83 

Annex B: Acknowledgements 87 



An Independent Review of the Work Capability Assessment - year two 

Foreword 



I was very pleased to be asked to undertake a second Independent Review 
of the Work Capability Assessment (WCA). 



As I pointed out in my Foreword to the first Review, society and its citizens 
have responsibilities to each other. The citizen is expected to earn their own 
living, and, as a consequence of that, to pay taxes to support society. In turn 
society has responsibilities to the citizen, including supporting those who are 
unable to earn a living for themselves. 



Assessing a person's fitness for work through the WCA is part of that: 
determining who can work and who needs state support. The WCA is the right 
concept. The first year Review showed that the process of administering it 
was not working as well as it could or should. Revisions at all stages of that 
process were required to make it fairer and more effective. The reassessment 
of Incapacity Benefit claimants from April 201 1 has greatly increased the 
workload of all those involved: Department for Work and Pensions (DWP) 
Operations 1 , Atos Healthcare, the claimant's chosen healthcare adviser and, 
not least, the claimant, who may not have had any health and work 
assessment for many years. This increases the imperative for the process 
to keep improving. 



Even without Incapacity Benefit reassessment, the changes I proposed to the 
WCA system would have presented a big challenge for two large and complex 
organisations, namely DWP Operations and Atos. DWP rapidly adopted my 
proposals as policy and DWP Operations set about the necessary changes 
with energy and commitment. Atos, who are contracted to DWP for their part 
of the WCA, fulfilled their contractual requirements. 



I have seen these improvements in the day-to-day running of both DWP 
Operations and Atos. This has taken time and some observers have told 
me that they have seen no change. I advise patience. The process of 
improvement is happening, but is not yet in evidence everywhere. It will take 
time to have the desired impact and the year three Review will closely monitor 
the impact of the changes and ensure there is continuing progress in 
improving the assessment. 



1 From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 



An Independent Review of the Work Capability Assessment - year two 

Whilst real progress has been made this year, I would not for one minute 
claim that things are perfect. Much criticism about the assessment - 
particularly from individuals - remains. This criticism should certainly not be 
ignored and the Call for Evidence this year was particularly helpful in getting 
views about the assessment and how it could be improved. 



The major charities and the clinicians who support their work have a 
considerable wealth of knowledge at their disposal relating to the disabilities 
and illnesses that they represent. Their assistance in making 
recommendations for improvements to the descriptors has, I believe, been a 
successful process. Their involvement in developing and updating guidance 
and support materials for those undertaking the assessments would also be 
helpful. 



No real progress has been made with recommendations relating to the 
appeals process, particularly around feedback from Tribunals to Decision 
Makers about reasons for overturn of appeals. This is very disappointing. 
I have had a lot of positive feedback from a lot of people about this idea, and 
I am certain that it would improve the WCA process - and performance within 
it - if implemented. However, the First-tier Tribunal President has informed 
me that judicial matters are outside my remit. 



Communications before, during and after the WCA also remains problematic. 
Messages about the WCA and what a 'fit for work' decision means need to 
improve within DWP Operations. There is a need to move away from the view 
of the assessment as something that people either 'pass' or 'fail'. And finally 
there appears to be a need to improve communications between DWP 
Operations and the Work Programme providers to ensure that people who 
can work are given the opportunity to do so at the earliest opportunity. 



Aristotle is reputed to have said: "If we believe that men (sic) have any 
personal rights as human beings, they have an absolute right to such 
measure of good health as society, and society alone, is able to give them". 
Today we would argue that people have responsibilities for their own health 
as well, but society does have a role and the WCA is part of that. 



\U~^- 




Professor Malcolm Harrington 
November 2011 



An Independent Review of the Work Capability Assessment - year two 

Executive Summary 

1 . The Work Capability Assessment (WCA) was designed to assess an 
individual's eligibility for Employment and Support Allowance (ESA). It 
aims to distinguish between those people who could work; those people 
who could work at some point with the right support; and those people 
who cannot work and, therefore, need State support. 

2. The first Independent Review, published in November 2010, found that the 
WCA was the right concept for achieving this aim but that it could be 
impersonal and mechanistic and that there was a lack of transparency in 
the process with poor communication between the various parties. This led 
to poor decision making and a high rate of appeals, many of which were 
successful. 

3. A series of recommendations designed to improve the fairness and 
effectiveness of the WCA were proposed and were immediately accepted 
by the Government. 

Implementation of year one recommendations 

4. I am pleased to say that all the year one recommendations have been, or 
are being, implemented. The Department for Work and Pensions (DWP) 
moved swiftly to make the recommendations Departmental policy and 
DWP Operations 2 and Atos Healthcare have enacted these policy 
changes. 

5. The WCA has, in my view, noticeably changed for the better. However 
there is still further to go. Some of the improvements from my first Review 
have not reached all parts of DWP Operations. 

6. To those who feel nothing has happened, I say: be patient. It is happening. 
The process is not yet perfect, but it is improving and will continue to 
do so over the course of the five Independent Reviews. 

Key findings and themes from this Review 

7. Whilst the year one Review, and associated recommendations, considered 
the WCA process and how that could be improved, the year two Review 
has focussed on a number of more specific issues which the first Review 
did not have time to consider in detail and which will support the 
recommendations from year one. 



2 



From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 



An Independent Review of the Work Capability Assessment - year two 

8. In this Review I propose a number of more detailed recommendations 
to improve further the process of the WCA and the criteria used to 
determine eligibility for ESA. 

9. This Review sets out a series of recommendations which complement - 
and build on - the recommendations from the year one Review. They aim 
to improve the fairness and effectiveness of the assessment by: 

• Better communications and sharing of information between all 
parts of the system 

This will mean that everyone involved knows their roles and 
responsibilities and that the purpose of the WCA and the reasons for 
decisions are better understood. This is particularly the case between 
Decision Makers and Personal Advisers within DWP Operations so that 
reasons for reaching a decision and what that decision actually means 
are clear. Although there is no clear evidence that 'employability' 
should feature in the WCA, Decision Makers and the Work Programme 
providers should liaise more closely so that the latter are better able to 
help people back into work. 

Whilst the First-tier Tribunal President considers it to be outside the 
remit of the Review, better communication between the First-tier 
Tribunal and Decision Makers so that reasons for upheld appeals are 
clear would also considerably add to the fairness and effectiveness of 
WCA process. 

• Increasing and improving the transparency of the assessment 

DWP and Atos need to engage with representative groups and their 
clinical advisers to ensure that Decision Maker and healthcare 
professional guidance used during the WCA process is up-to-date and 
clinically sound; and the regular publication of Atos data will ensure 
consistency and that standards are not allowed to slip. 

• Ensuring quality decisions are made 

Regular audit of Decision Maker's performance is needed to ensure 
they are making consistent, robust and evidence-based decisions and 
that - as newly empowered Decision Makers - they are accountable 
for their decisions. 

• Monitoring the impact of recommendations from the Independent 
Reviews 

This will help ensure, and provide evidence, that the changes are 
having the desired impact. This could be achieved by collecting indices 
for change on the rate and amount of progress made; and carrying out 
research into what happens to people who are placed in each group 
over time. 



8 



An Independent Review of the Work Capability Assessment - year two 

• Further decisions need to be made on the proposals for new mental, 
intellectual and cognitive descriptors once further research has 
compared the proposed descriptors with the current ones. I hope that it 
will be possible to consider similar research for the recently submitted 
proposals for refining the fluctuating conditions descriptors, or for them 
to join this process. 

Costs and benefits 

10. 1 recognise that, if adopted, these recommendations will have a cost 
implication attached to them. 

1 1 . However, as with the year one recommendations, seen in the wider 

context the proposed changes are likely to be cost saving or cost neutral in 
the medium- to long-term by ensuring that decisions are right first time and 
by ensuring that all parties understand why a particular decision has been 
reached and its implications. 



9 



An Independent Review of the Work Capability Assessment - year two 

Chapter 1 : The Review outline 

The Work Capability Assessment 

1 . The Work Capability Assessment (WCA) was introduced in October 2008. 
It assesses an individual's entitlement to Employment and Support 
Allowance (ESA), a benefit that provides support to people who are out 
of work and have a disability or health condition. 

2. The WCA intends objectively to evaluate a persons' capability for work 
so that appropriate support can be provided to help them back to work or, 
if they cannot work, unconditional support is provided. As such, the 
assessment focuses on the claimant's functional capability rather than 
their diagnosis. 

3. The three Groups into which a claimant can be placed and a broad outline 
of the WCA process were all described in more detail in the first 
Independent Review. 3 

Independently reviewing the WCA 

4. The Welfare Reform Act 2007 legislated for the introduction of the WCA. 
This law provides the basis for the Independent Reviews. Section 10 
states that: 

"The Secretary of State for Work and Pensions shall lay before Parliament 
an independent report on the operation of the assessment annually for the 
first five years after those sections come into force. " 

5. In November 2010, Professor Malcolm Harrington, an occupational health 
specialist, published his first Review. He found that the WCA is the right 
concept, but that improvements could be made to each stage of the 
process. 4 His Review made a number of recommendations all of which 
the Government accepted and most of which have now been implemented 
(see Chapter 2). 

This review 

6. In November 201 1 , the Secretary of State for Work and Pensions 
re-appointed Professor Harrington to carry out the second Independent 
Review of the WCA. 



3 



Chapter 3, paragraphs 1-5 of "An Independent Review of the Work Capability Assessment" 
Harrington, 2010. 

lary, paragraphs 3-4, ibid. 

11 



4 Executive Summary, paragraphs 3-4, ibid 



An Independent Review of the Work Capability Assessment - year two 

7. It aims to provide: 

• a further examination of the system based on a series of 
recommendations made in the first Review; 

• updates on progress implementing the year one recommendations 
and, where possible, their impact; and 

• a future programme of work for year three. 



The terms of reference for the Review: 

• To provide the Secretary of State for Work and Pensions with an annual 
independent report evaluating the operation of the assessments of limited 
capability for work and limited capability for work-related activity; 

• To evaluate the effectiveness of the limited capability for work assessment 
in correctly identifying those claimants who are currently unfit for work as a 
result of disease or disability; 

• To evaluate the effectiveness of the limited capability for work-related 
activity assessment in correctly identifying those claimants whose disability 
is such that they are currently unfit to undertake any form of work-related 
activity; 

• To take forward the programme of work identified in the year one report 
during years two and three; 

• To monitor and report on the implementation of the recommendations in 
the year one report that are adopted by Ministers; and 

• To provide independent advice to Ministers and the Department on any 
specific issues or concerns with the WCA that arise during the term of 
appointment, which the Government may seek your independent view. 



8. The Secretary of State also re-appointed an Independent Scrutiny Group 
to oversee Professor Harrington's work and to provide him with advice and 
challenge during the course of his work. The group included experts from 
the medical profession, disability groups, occupational health and 
employers. The group was chaired by Professor David Haslam, a GP, 
National Clinical Adviser to the Care Quality Commission and current 
President of the British Medical Association. The three other members of 
the group were Paul Farmer, Chief Executive of Mind; Dr Olivia Carlton, 
President of the Faculty of Occupational Medicine and Head of 
Occupational Health, Transport for London; and Neil Lennox, representing 
the CBI and Head of Health, Safety and Fire at Sainsbury's. 



12 



An Independent Review of the Work Capability Assessment - year two 

9. The Group met with Professor Harrington on four occasions during the 
course of the Review. The Group used these meetings to challenge 
constructively Professor Harrington's findings, to ensure that the process 
by which the Review was carried out was fair and robust, and to ensure 
that it remained within the terms of reference given by the Secretary of 
State. 



The terms of reference for the Independent Scrutiny Group: 

• To ensure that the process for conducting the review is robust, 
comprehensive and fair and reflects the terms of reference for the review; 

• To ensure the process for gathering evidence and relevant data is in 
accordance with accepted standards and best practice; 

• To monitor progress of the review to ensure it remains on plan and discuss 
and challenge emerging issues and findings; 

• To be available to the Reviewer to provide advice and support as the review 
progresses; 

• To provide challenge as the final report is formulated to ensure the findings 
are robust and are presented in a clear and appropriate format; and 

• To ensure the reviewer maintains his independence, acting as a point of 
contact and sounding board where necessary. 



The scope 

10. As the second of five annual reviews, the programme of work was largely 
determined by a series of recommendations in the first Review. These 
recommendations were that in year two the Review should: 

• examine the mental, intellectual and cognitive descriptors and provide 
recommendations on refining them; 

• examine the descriptors, in particular how they account for other 
fluctuating conditions and, possibly, generalised pain and provide 
any recommendations necessary; 

• examine what happens to people who are found Fit for Work, people 
who are placed in the Work Related Activity Group, in the Support 
Group and people who do not complete their WCA; 

• examine what happens to individuals who are found Fit for Work but 
are unable to claim Jobseeker's Allowance; 

• undertake research understand whether the assessment could and 
should incorporate more "real world" or work-focused elements; 



13 



An Independent Review of the Work Capability Assessment - year two 

• examine the Atos computer system (LiMA) and how it can drive the 
right behaviours; 

• explore the use of other healthcare professionals in the Atos 
assessments and to check consistency of assessments by different 
professions; and 

• monitor the implementation of those recommendations in the year one 
report which have been adopted by Ministers. 

1 1 . In January 201 1 a further piece of work was added to consider the wording 
of the descriptors used for claimants receiving treatment for cancer. 

The process 

12. The Review took an open and collaborative approach to gathering 
information for this report. Many sources of data and evidence were 
interrogated to ensure that information, data and opinions expressed 
could be cross-checked and challenged. 

The Call for Evidence 

13. A considerable amount of information was gathered through a Call for 
Evidence. This exercise enabled anyone with an interest to submit their 
views and any evidence that related to the WCA. 

14. The Call for Evidence was launched on 14 July 201 1 and closed on 
16 September 201 1 , although considerable leeway was afforded 
organisations and individuals who could not meet the deadlines involved. 
During this time, over 425 individuals, representative groups, unions, 
employers, employment support providers and healthcare professionals 
(HCPs) responded. 

Stakeholder meetings and seminars 

15. The Review met with around 75 stakeholders through a series of one-to- 
one meetings, group meetings and seminars. At each, stakeholders and 
interested groups were given the opportunity to provide evidence. 

Examination of all parts of the process 

16. The Review examined all, and visited many, parts of the WCA process 
during the course of the year. 

The Department for Work and Pensions (DWP) 

17. The Review visited 5 Benefit Delivery Centres over the course of the year, 
including a number of unannounced visits. 

18. These visits provided an opportunity to speak to managers and Decision 
Makers about recent and future changes and the impact which these 
changes might have. 



14 



An Independent Review of the Work Capability Assessment - year two 

19. A dialogue was also maintained with DWP Ministers and senior officials 
from DWP. 

Atos Healthcare 

20. The Review visited Atos Assessment Centres and spent time at an Atos 
Training Centre viewing the training provided to newly recruited nurses. 

21.lt also had access to Atos management information (even where this 
information was not in the public domain), training materials, spent time 
with the independent audit assurance team and was able to view first 
hand the LiMA computer system as well as organising three stakeholder 
seminars to look at this in more detail. 

First- and Second-tier Tribunals and Work Programme Providers 

22. Finally, the Review had an ongoing dialogue with both the Tribunal Judges 
and several of the Work Programme providers during the course of the 
year. 

Work and Pensions Select Committee 

23. The Reviewer gave evidence to the Work and Pensions Select 

Committee's investigation into the role of Incapacity Benefit reassessment 
in helping claimants into employment in May 201 1 . 



15 



An Independent Review of the Work Capability Assessment - year two 

Chapter 2: Implementation of the 
year one recommendations 

Year one recommendation 

1 . In year two the Review should monitor the implementation of those 
recommendations in the year one report which have been adopted 
by Ministers. 

Background 

2. The first Independent Review of the Work Capability Assessment (WCA) 
was published on 23 November 2010. It contained 25 recommendations 
of which: 

• seventeen related to the year one Review; and 

• eight concerned new work to be undertaken in year two. 

3. The Government immediately accepted all of the recommendations. 

4. In January 2011, a further piece of work was added. This additional task 
was initially assigned to Macmillan Cancer Support and addressed the 
wording of the provisions used for claimants receiving treatment for 
cancer. 

5. The year one recommendations can be divided into four groups: 

• the customer experience; 

• the Atos face-to-face assessment; 

• the decision making process; and 

• the appeals process. 

Incapacity Benefit Reassessment and new 
Employment and Support Allowance (ESA) claims 

6. In April 2011 the Government began reassessing all claimants claiming 
Incapacity Benefit for eligibility for Employment and Support Allowance 
(ESA) using the WCA. 



17 



An Independent Review of the Work Capability Assessment - year two 

7. Given the size of this undertaking the Government decided to implement 
all the year one recommendations for the Incapacity Benefit reassessment 
cases first (following trials in Aberdeen and Burnley) and then to extend 
this to new ESA claimants later. Of the 14 year one recommendations for 
Department for Work and Pensions (DWP) Operations 5 and Atos, 1 1 have 
been delivered and the remaining ones are on track to be implemented by 
the end of 2011. 

8. The Review saw, at first hand, the undoubted effectiveness of the new 
procedures when it visited Aberdeen in May 201 1 . The Decision Makers 
appeared empowered and enthusiastic about their enhanced 
responsibilities and initial feedback from claimants was also positive. 

9. A visit to Plymouth Benefit Delivery Centre, also in May, revealed that 
although the formal re-training packages were not yet in place there, the 
manager was already creating greater autonomy for the Decision Makers 
and had relaxed the rigid throughput figures. The Decision Makers, for 
their part, were empowering themselves on the basis of their knowledge of 
the year one recommendations and in advance of formal training. This was 
most encouraging to observe. 

The customer experience 

10. DWP Operations have initiated, or completed, work to reform the 
claimant's experience from providing additional information for the 
claimant at the start of the WCA process; to improving the contents of 
the ESA50 form; and finally having additional contact with the claimant 
following the Atos face-to-face assessment when a decision about 
entitlement to ESA is being made. 

11. Following the early implementation in Wrexham and Oldham Benefit 
Delivery Centres, additional contact with the claimant has now been 
introduced nationally. There is now clearer information about the WCA 
process and the outcomes. The ESA50 form has been revised, including 
space for a paragraph from each claimant to explain how their ill-health or 
disability affects them. The follow-up letters have also been made clearer 
and less threatening. These steps - and those involving the enhancement 
of the role of the Decision Maker - are shown in Figure 1 . 



5 



From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 

18 



An Independent Review of the Work Capability Assessment - year two 

Figure 1: claimant journey following implementation of year one 
recommendations 



Someone calls to check that I understand 
what will happen next; stressing to me the 
importance of fully completing the ESA50 

questionnaire, identifying my chosen 

healthcare advisor, providing additional 

evidence, and if required attending the 

WCA appointment. (This change is 

being further evaluated and has not yet 

been introduced nationally) 



I receive a letter 
informing me of 
my benefit award 



rz 




I receive a letter telling 
me what will happen next, 
explaining the importance 
of completing the ESA50 
questionnaire, providing 
any additional information 
and, if required, attending 
the WCA face to face 
appointment. 



Someone calls to 
arrange a WCA 

face to face 

appointment at 

an Assessment 

Centre 



The Decision Maker calls to 
discuss my entitlement to 
ESA prior to making a final 
decision. I can discuss the 
reasons for the decision and 
provide further evidence to 

support my claim. I am 
advised of my options and if 

I wish to claim JSA I am 

transferred to someone who 

takes my claim details 



I receive a letter 

informing me of the 

benefit disallowance 

and the WCA outcome. 

(A trial of issuing the 

Decision Makers 

Justification at this 

stage is being 

completed). 



v 



I receive a 
notification 

advising me of 
the appeal 

outcome and 
options. 



Someone calls to 

confirm information for 

a reconsideration 



Key: Q_J new steps introduced into the ESA process (steps 2,8,12 introduced nationally from 31 October 201 1 ). These new steps apply 
to both new ESA claimants and existing claimants re-referred for a WCA on and after 31 October 2011. 

12. A number of DWP Decision Makers responded to the Call for Evidence 
reporting positively on the introduction of these telephone contacts. 

In their experience, many claimants had responded positively to them. 
This was encouraging to hear and the Review looks forward to monitoring 
developments in year three. 

The Atos face-to-face assessment 

13. The personalised summary statement to conclude the face-to-face 
assessment in plain English was introduced nationally by Atos in 
June 2011. Since then Decision Makers have been using the statement 
as part of the decision making process. 

14. DWP Operations expect to reach a conclusion soon as to when and to 
which claimants this personalised summary statement should be issued. 
The Review has had extensive discussions with senior DWP staff over this 
and understands the need to issue the statement to the right claimants, 

in the right context, at the right time. 



19 



An Independent Review of the Work Capability Assessment - year two 

15. It has also been suggested that a better approach would be to issue the 
Decision Maker's Justification instead if a claimant is disallowed. There are 
clear advantages to this proposal, especially as the Decision Maker is 
the one determining eligibility for the benefit and because the Decision 
Maker's written report would cover all aspects of the claim, not just the 
Atos section. 

16. This seems to be a considerable improvement on the year one 

recommendation. It also demonstrates the importance of field testing and 
reviewing the recommendations in real life situations. DWP Operations 
deserve congratulating for improving on the recommendations, rather than 
simply following a policy laid down following an Independent Review. The 
Review looks forward to seeing the impact of this change as and when it is 
made. 

17. Mental Function Champions have been trained and have been in place 
on a regional basis since May 201 1 . The initial recommendation for a 
Champion in each Assessment Centre was logistically impossible. The 
Review has been convinced that a regional approach is more efficient, 
conserving scarce resource and still delivering the desired result. The 
impact of Champions on the quality of assessments for people with 
mental, intellectual and cognitive conditions remains to be evaluated 
and monitored, and the Review will in turn monitor this. 

18. However, initial evidence from Atos does suggest that Mental Function 
Champions are being well utilised, with an average of around 10 calls 
to the helpline each day. Anecdotal evidence also suggests that Atos 
healthcare professionals (HCPs) welcome the support and advice 
available from the Champions: 

"I personally have found this service to be invaluable. I am lucky in that 
I have two very experienced HCPs who are Mental Function Champions 
at the assessment centre I work at and so am able to ask them for advice, 
which I do regularly, especially since I have been in the company only 
six months", Atos HCP 

19. Atos have piloted the audio recording of assessments and the evaluation 
of this exercise is proceeding. No decision on implementing or extending 
this will be made until the validity, cost and feasibility of the process has 
been assessed. 

20. Atos have published a customer charter and it is in place at all 
Assessment Centres. 



20 



An Independent Review of the Work Capability Assessment - year two 

The decision making process 

21 . Putting the Decision Maker back at the heart of the WCA was the central 
plank of the year one recommendations. They were tasked specifically 
with: 

• liaising more closely with the claimants; and 

• collecting as much corroborating evidence as possible from the 
claimant in support on their case, including from a claimant's chosen 
healthcare adviser. 

22. As a result new learning material has been made available to Decision 
Makers. The object of this and the accompanying training packages was 
to improve their understanding of the WCA and how to gather and use 
additional evidence from the claimant before making a final decision. 

23. All Decision Makers should have completed the new training by the end of 
2011. To date, all Incapacity Benefit reassessment Decision Makers have 
received their training, as have over half of ESA claims Decision Makers. 

24. A new Quality Assessment Framework has been introduced to monitor the 
standard of decision making. It is now in place for Decision Makers in both 
Incapacity Benefit reassessment claims and ESA claims. 

25. Improving the communication between Atos HCPs and the Decision 
Makers has been trialled. The Review has seen at first hand that where 
this has been done it has been a valuable resource, particularly for 
Decision Makers who have had the opportunity to discuss difficult cases 
or complex medical evidence with Atos HCPs or to understand better the 
recommendations made by Atos following the face-to-face assessment. 
However, there has been no national roll-out of this, instead a telephone 
adviceline is being introduced. 

26. Increased use of the reconsideration process is now a standard part of 
the later stages of the claimant journey. This is proving to be useful as 
additional medical information from the claimant often only comes to light 
at this stage. In an ideal world, the Decision Maker should have this 
evidence early in the process, but the fact that it is being considered 
routinely before an appeal needs to be invoked is an advance on 
previous practice. 

The appeals process 

27. Modifying the appeals process is not strictly the preserve of DWP. The 
Review has actively engaged in dialogue with the First- and Second-tier 
Tribunals and has spoken at national meetings of both groups of Judges. 



21 



An Independent Review of the Work Capability Assessment - year two 

28. Detailed and constructive discussions have continued throughout the year 
with both the First-tier Tribunal President and the Chief Medical Member. 
As part of these discussions, the First-tier Tribunal President has made 

it clear to the Review that the appeals process is outside of its remit. 
However, the Reviewer, and the Independent Scrutiny Group which 
oversees his work, still believes that improvements to the whole WCA 
process, including appeals, would improve both its fairness and 
effectiveness and so hopes this dialogue will be maintained. 

29. The development of a summary feedback to the Decision Maker 
concerning the reason(s) for appeals being upheld is continuing. 
The suggestion is to have a short list of reasons which could be 
transmitted electronically to each Decision Maker for each upheld case. 
The Administrative Justice and Tribunals Council, the Administrative 
Justice policy section of the Ministry of Justice and the Social Security 
Advisory Committee have approved the idea. 

30. A draft scheme for these one-liners (see Table 1) has been submitted to 
the First-tier Tribunal President with a view to a trial of the system. Whilst 
the First-tier Tribunal President is broadly supportive of this idea, he has 
made it clear that this is outside of the Review's remit. 

Table 1: draft summary feedback from Tribunals to Decision Makers 



CORRECTLY MADE DECISIONS OVERTURNED BY TRIBUNALS 



The Tribunal was given additional evidence which was not available to the 
Decision Maker. 



The Tribunal considered the same evidence as the Decision Maker but 
formed a different view. 



The medical panel member interpreted medical evidence differently to Atos. 



The presence of the appellant at the hearing had a significant impact on the 
outcome, shedding new light on existing evidence. 



INCORRECT DECISIONS OVERTURNED BY TRIBUNAL 
REASON FOR INCORRECTNESS 



The Tribunal concluded that the Decision Maker had failed to gather 
sufficient facts/evidence to reach an equitable outcome. 



The Tribunal considered evidence that was available to the Decision Maker 
but which he or she disregarded/was unwilling to accept. 



22 



An Independent Review of the Work Capability Assessment - year two 



The decision was based on a misinterpretation/misunderstanding of the 
available evidence. 



The Decision Maker took into account wholly unreliable evidence. 



The Decision Maker overlooked a relevant Commissioner's decision/Court 
decision which was or should have been available to him. 



The Decision Maker failed to request adequate medical guidance. 



The Atos medical report contained inaccuracies/was of poor quality, for 
example underestimated the severity of appellant's disability. 



The Decision Maker failed to identify/resolve an obvious conflict in the 
evidence. 



The Decision Maker did not action additional relevant evidence provided 
after his decision was made and initiate a revision. 



Other error discovered. 



31 . If agreed and implemented, this list would also has the advantage of 
providing aggregated data for DWP Operations at either a regional or 
national level so they are able to understand better why appeals are being 
upheld. This means that Decision Maker performance could be improved 
at a macro as well as micro level. 

32. A review of training given to medical and legally qualified members of 
the Tribunal has been undertaken and details of this are contained in 
Chapter 6. 

33. Recommendation 17 stated: 

"The Review recommends that training offered by the Chamber President 
to Tribunal Judges and Medical Members should include modules on the 
evidence of the beneficial effects of work to an individual's well-being" 

34. At a meeting with the First-tier Tribunal Judges it was pointed at that it is 
not their responsibility to consider such socio-medical issues. Their role is 
to interpret the law as it relates to the WCA. The Review stands corrected 
and this aspect of the training recommendation has not been pursued. 



23 



An Independent Review of the Work Capability Assessment - year two 

35. No progress has yet been made with the recommendation concerning the 
monitoring of appeal outcomes within and between Tribunals. The Review 
has heard further anecdotal evidence that suggests that the proportion 

of upheld appeals may vary widely between Tribunals, and between 
individual judges, and considers it important to understand whether 
and why there is any difference in outcomes between Tribunals. 

36. A request for provision of statistical information, if it indeed exists, has 
been made to the First-tier Tribunal President. He has now responded 
by pointing out that such aspects of the Review's work on the WCA are 
outside its remit. The Review would welcome work in this area in the 
future, but recognises that it is an area of judicial responsibility. 

Unannounced visits 

37. Visiting Benefit Delivery Centres as part of a planned programme 
organised by DWP Operations could lead to the accusation that the 
Review would only see the best practice in Centres primed for a visit. This 
potential perception problem was discussed with the Scrutiny Group. The 
view emerged that unannounced visits to some major Centres, following 
the example of senior managers at large employers such as Sainsbury's, 
would be informative. 

38. The initiative was put to senior DWP officials and endorsed by them. 
Subsequently a list of potential Centres of sufficient size was drawn up. 
There were no restrictions on which sites were visited and when. The plan 
was that each visit would last no longer than an hour and would be an 
opportunity to question managers and Decision Makers about their 
experience of the new recommendations in practice. They would be 
asked whether the WCA process was improved for them and their 
claimants and, if not, why not. 

39. Such visits subsequently took place at two sites: Merthyr Tydfil and 

Gloucester. At Merthyr, it was fortuitous that the day of the visit coincided 
with the second day of the three day training course for Decision Makers 
on the implementation of the year one recommendations. There was 
an opportunity to talk to the manager who was well versed in 'lean' 
techniques and who was totally wedded to the new 'change' culture. 
The Decision Makers were enthusiastic about their enhanced role and 
had nothing but positive things to say about their new, yet more onerous, 
responsibilities. It was a most encouraging visit, given the large work 
load with which a Benefit Delivery Centre like Merthyr has to cope. 



24 



An Independent Review of the Work Capability Assessment - year two 

40. At Gloucester the manager provided the Reviewer with an opportunity to 
discuss, in seminar fashion, the impact of the year one recommendations 
with 15 staff who were either Decision Makers or Appeals Writers. It was a 
most valuable experience and much appreciated by both the staff and the 
Reviewer. In general their attitudes and experiences mirrored those in 
Merthyr. They did, however, feel that the Decision Makers should be given 
more discretion in the number and style of telephone calls to claimants. 

41 .At both Gloucester and Merthyr the Decisions Makers were deeply 
frustrated by the lack of feedback from the Tribunals on the reasons 
for upheld appeals (see paragraphs 29 to 31). 

The impact and effect of the year one 
recommendations so far 

42. Making changes to the workings of two large organisations such as 
DWP Operations and Atos cannot be achieved overnight. At the outset, 
DWP confirmed that all the recommendations were now policy. The 
implementation would take time. Some items could be put in place quickly, 
others would take months to execute. Some would need to be trialled and 
revised before national roll-out. Atos would, as part of their DWP contract, 
be required to carry out the changes necessary to implement the relevant 
recommendations. 

43. The Call for Evidence issued in July 2011 specifically asked respondents 
for robust evidence about whether some or all the year one 
recommendations were in place at that time. 

44. Whilst recognising that it is probably too early to be able to provide robust 
evidence about implementation at this stage, the vast majority of 
respondents reported that the process had broadly stayed the same 

or that they had not noticed any changes, primarily due to time: 

"Although DWP and Jobcentre Plus [DWP Operations] are making clear 
efforts to improve the system, it is clear that the reforms are taking time to 
translate into improvements for claimants", Disability Benefits Consortium 

45. Some were positive about the changes to date, even if recognising that 
more work was needed before the full effects of the changes are felt: 

"I think the changes to the way we reconsider a case has vastly improved. 
I am pleased to say that the new process genuinely provides a good level 
of service, sometimes outstanding. Please keep the telephone call in the 
process", DWP Operations Decision Maker 

"The process in some cases is improving. It does appear that in some 
cases the decision makers have been allowed to enter into dialogue 
and give consideration to evidence other than that provided by Atos", 
East Dumbarton CAB 



25 



An Independent Review of the Work Capability Assessment - year two 

46. However, some respondents did report negatively on the implementation 
of the recommendations, noting particularly the increase in time taken for 
claims to be processed and the remaining lack of clarity in the process: 

"Lack of clarity, information to individuals called for re-assessment is slow, 
and of poor quality, which has the effect of heightening anxiety and stress 
in those individuals I work with", Neath Port Talbot Council 

47. In August 201 1 , a series of seminars was convened with the major 
representative groups, patient support groups and the Work Programme 
providers. The outcome of these discussions reflected responses to the 
Call for Evidence and suggested that although few organisations had seen 
any change some positive messages were starting to get back to them. 
Most saw little change yet, but the more circumspect thought this would 
come soon. Some, disappointingly, saw no change for the better and did 
not expect to see any. This last opinion is not shared by the Review. 

48. The Disability Benefits Consortium's response to the Call for Evidence 
included the results of a survey of 439 welfare rights advisors during the 
period 19 July 2011 to 16 August 2011. 6 

49. Reviewing evidence for improvements in the claimants' experience of 
the ESA process from the beginning of 201 1 , less than 4% saw 
improvements, whilst 75% reported no change. Less than 2% of 
respondents reported any increased empowerment by Decision Makers. 

50. Some did recognise an improvement in written communications since 
January 2011 (10-16% depending on specific issues) and a third of 
respondents noticed an increase in the reconsideration process. 

51 . In some ways, these fairly negative results are not surprising. The 
Disability Benefits Consortium themselves recognise the possibility for 
bias given the sample population. Furthermore, most of the changes to the 
claimants' journey were not implemented until the middle of the year at the 
earliest and so would not have had a significant impact when the survey 
was conducted. 

52. Repeating such a survey in 2012 might be a better guide to changes in the 
process and the Review would very much welcome seeing the results. 

Conclusions 

53. Evidence collected at first hand by the Review and from numerous 
meetings with DWP staff proved conclusively that the recommendations 
are being enacted. The will to achieve change is strong among senior 
staff and the energy to apply them at local level by the Decision Makers 
is impressive. 



6 http://www.disabilityalliance.org/dbcharrington2.pdf 



26 



An Independent Review of the Work Capability Assessment - year two 

54. Inevitably, the whole process has been time consuming but the Review 
believes that positive changes are in the pipeline. A little patience would 
be valuable here from the critics, but a recommendation for year three will 
be to report, in detail, on progress using a series of agreed indices. For 
example, any reduction in the rate of successful appeals may be one 
indicator of change for the better although it is not the only one. 

55. Whilst the implementation of the recommendations at different times for 
Incapacity Benefit reassessment and ESA claimants is understood from a 
practical point of view, there appears to have been some confusion about 
what this meant in reality. Once all of the recommendations have been 
implemented for every claimant going through the WCA noticeable 
improvement in the process can be expected to be seen. 

Recommendations 

56. This Review has reported real appetite for change in both the Department 
and Atos, and has noted the positive changes that have been made as a 
result of the year one recommendations. Unfortunately this view is at odds 
with many of the respondents to the Call for Evidence. 

57. To better establish the rate and amount of progress made it would be 
helpful to consider in detail the data which DWP Operations collects 
routinely. 

Implementation of the Review's recommendations should be 
monitored overtime and on a regular basis, including focus on: 

• Percentage of claimants failing to return the initial ESA50 
questionnaire; 

• Percentage of claimants failing to attend the face-to-face WCA 
appointment; 

• Percentage of decisions meeting criteria in the Decision Making 
Quality Assessment Framework; 

• Percentage of reconsiderations received; 

• Percentage of decisions changed following reconsideration; 

• Percentage of appeals received; and 

• Percentage of appeals upheld. 

58. To ensure recommendations are being implemented in practice it is vital 
that their impact is monitored over time. DWP Operations are best placed 
to do this using the indices outlined above, although evidence collected 
from other sources, such as the Disability Benefits Consortium survey 
of welfare rights advisers, will help build the evidence base. 



27 



An Independent Review of the Work Capability Assessment - year two 

In year three the Independent Reviewer should pursue the year one 
recommendations about monitoring performance within and between 
Tribunals and trialling the one-line summary of reasons for upheld 
appeals. 

59. As noted in paragraphs 27 to 36 above, little progress has been made 
with these recommendations from the first Review. They are, however, 
important recommendations to understanding more about how and why 
appeals are upheld which the Review believes would considerably add 
to the WCA process. 

60. As noted earlier, the First-tier Tribunal President considers these 
recommendations to be outside the remit of the Review. A dialogue will 
be maintained to try and progress this, especially the summary one-liners. 

Unannounced visits to both Benefits Delivery Centres and Atos 
Assessment Centres should be carried out during the year three 
Review. 

61. Given the importance of monitoring the impact of the implementation of the 
Review's recommendations it seems sensible, building on the success of 
the unannounced visits to Benefit Delivery Centres this year, to allow the 
Review access to more Benefit Delivery Centres and to Atos Assessment 
Centres. 

62. This would not constitute a formal audit of the Centres and the people 
carrying out the WCAs, but would provide real insight into how things are 
changing and what people involved in the process make of those changes. 

63. However, in order to get a truly representative picture of national 

implementation it will be important for these visits to consider issues such 
as geography, the demographics of claimants and whether the Centres 
involved are dealing with ESA claims and/or Incapacity Benefit 
reassessment claims. 



28 



An Independent Review of the Work Capability Assessment - year two 

Chapter 3: Descriptors 

Year one recommendation 

1 . The first Review suggested that the descriptors used in the Work 
Capability Assessment (WCA) needed detailed scrutiny and possible 
revision. 7 

2. As a result the Review agreed to work with a number of representative 
groups and independent experts to provide recommendations on: 

• the mental, intellectual and cognitive descriptors; 

• the approach to assessing fluctuating conditions 8 ; 

• the provisions for people undergoing treatment for cancer; and 

• whether the assessment could and should incorporate more 'real world' 
or work-focused elements. 

3. It was agreed with Ministers that - rather than wait until the end of the 
year - any recommendations from the Review would be submitted to the 
Department for Work and Pensions (DWP) over the course of the year. 

Plan of action 

4. Broadly speaking each of the four workstreams followed the same 
process: 

• Establish a group of relevant representative groups to make initial 
recommendations for refinements and improvements. 

• Establish the terms of reference and the scope of the group, including 
a timetable for the work. 

• Establish an independent Scrutiny Group of experts to critique the 
recommendations made by the representative groups and to work with 
them to iterate and agree improvements to the initial recommendations. 

• Once the Scrutiny Group and representative groups had agreed a final 
set of recommendations these were submitted to the Review. These 
were then reviewed and critiqued by the Reviewer before either 
accepting them and submitting them to DWP; modifying them before 
submitting them to DWP; or rejecting them/asking for further work on 
them before considering them again. 



7 Chapter 8, paragraphs 2-9, "An Independent Review of the Work Capability Assessment" 
Harrington, 2010. 

8 For ease referred to as 'the fluctuating conditions descriptors' although this is more an 
approach than having specific descriptors. 

29 



An Independent Review of the Work Capability Assessment - year two 

Mental health descriptors 

5. Mental and behavioural disorders still make up the largest group of 
Employment and Support Allowance (ESA) claimants, with 35 per cent of 
people going through the WCA being recorded as having a mental and/or 
behavioural condition as their primary condition. 9 This does not take into 
account the many more people who have a mental and/or behavioural 
condition as a secondary condition. 

6. The year one Review also noted how many people believe that mental, 
intellectual and cognitive conditions are poorly accounted for under the 
WCA, especially where people may be unwilling or unable to explain the 
extent of their problems. 

Development of recommendations 

7. In September 2010 Mind, Mencap and the National Autistic Society were 
asked to provide recommendations on refining the mental, intellectual and 
cognitive descriptors used in the WCA. 

8. They presented initial recommendations to an independent Scrutiny Group 
in December 2010. This Scrutiny Group comprised of: 

• Tom Sensky (Chair), Emeritus Professor of Psychological Medicine, 
Imperial College; 

• David Henderson-Slater, Consultant in Neurological Disability and 
Rehabilitation Medicine, Senior Research Fellow, University of Oxford; 

• Josanne Holloway, Consultant Forensic Psychiatrist, Greater 
Manchester West Mental Health NHS Foundation Trust; 

• Paul Litchfield, Chief Medical Officer, BT Group; 

• Molly Meacher, Chair, East London NHS Foundation Trust; 

• Donna Pereira, Occupational Therapist and Head of Staff Health and 
Welfare, West London Mental Health NHS Trust; and 

• Rachel Perkins, Freelance Consultant, Recovery- Employment - 
Participation. 

9. Generally speaking there was broad agreement between the 
representative groups and the Scrutiny Group about the proposals. This 
was particularly the case on some of the conceptual issues such as the 
need to focus on what a person can do (with help and/or adjustments) 
rather than what they cannot; the relevant weighting of the descriptors; 
and the focus on frequency, severity and duration improving the accuracy 
of the assessment. In April 2011 the Scrutiny Group and representative 
groups made their joint recommendations to the Review. 



9 Table 7, 
http://research.dwp.gov.uk/asd/workingage/esa_wca/esa_wca_25102011_tables.xls 

30 



An Independent Review of the Work Capability Assessment - year two 



10. Their recommendations: 



• 



Went back to the fundamentals of each descriptor to examine what 
it should be measuring, and concluded that the descriptors need 
to be multi-dimensional in order to reflect the complexity of the 
impairments being assessed; 

• Attempted to account better for fluctuations in impairment, or 
intermittent impairments by trying to produce a more nuanced 
assessment of people's impairments. Their proposals were 
deliberately structured in such a way that they could be used as the 
direct basis for questioning the claimant and could be understood 
by the claimant; 

• Looked at the amount of help or support a person needs to 
overcome their impairments in order to work, rather than focusing 
on what they cannot do; and 

• Proposed going back up to ten descriptors, rather than using the 
seven descriptors which were being used from March 201 1 after 
implementation of the DWP's internal review. 

11. Having carefully considered the recommendations, the Reviewer was able 
to endorse them and submitted them to DWP in April 201 1 . In doing so 
there was a recognition that more work needed to be done to test and 
validate the evidence underpinning the recommendations. It was also clear 
that putting the proposed descriptors into an operational context would be 
one of the key things needing further consideration. 

12. Whereas the original recommendation from year one had suggested that 
recommendations should be received by the Review in late November and 
advice would be presented to Ministers soon after that, the complexity of 
this task meant that the timelines were necessarily extended. 

13. This is helpful in highlighting that, whilst there is much unease about the 
current descriptors from representative groups, gathering evidence and 
reworking them to be fairer, more effective, easily to implement and 
replicable is not straightforward. 

Departmental response 

14. The Department's response to the recommendations expressed a number 
of concerns about them. These focused on: 

• the lack of evidence base supporting the proposals, either that the 
current descriptors are not working as they should or that the proposed 
descriptors would improve the assessment; 

• the proposed matrix approach to scoring the descriptors potentially 
providing less transparency and consistency to the assessment and 
meaning that physical conditions would be assessed and scored in 
a different way to mental, intellectual and cognitive conditions; and 



31 



An Independent Review of the Work Capability Assessment - year two 

• the potential for added complexity in the assessment by trying to 
capture all the complexities of all mental, intellectual and cognitive 
conditions in the descriptors rather than using guidance to support 
the descriptors. 

15. Although the Reviewer did not necessarily accept all of these arguments, 
constructive discussions between the Review, the Department and the 
representative groups and Scrutiny Group identified several opportunities 
to make positive progress in the short-term whilst also building an 
evidence base to support any further, and potentially more fundamental, 
changes to the descriptors in the longer-term. 

1 6. In the short-term there was agreement to: 

• consider the ESA50 form and whether it is possible to incorporate 
elements of the recommendations around frequency, severity and 
duration into this so that initial evidence from claimants allowed more 
informed decisions; and 

• consider changes to specific words or language used in the current 
descriptors by clarifying their intent or application to help improve the 
assessment. 

17. In the longer-term there was agreement of the need to build an evidence 
base to inform any future changes to the mental, intellectual and cognitive 
descriptors. This could take the form of a 'gold standard' review to 
establish evidence of the way in which the current descriptors are working 
and to test robustly the proposed descriptors to see if they would improve 
the assessment. 

Current status 

18.DWP did not receive any suggestions from the representative groups 
about the specific wording or language used in the current descriptors. 

19. An initial and constructive meeting about the ESA50 was held between 
DWP and the representative groups in October 201 1 . It was agreed that 
the representative groups would produce a suggested improved version of 
the ESA50. No timescales were agreed for this, although the expectation 
is that this will happen relatively quickly. 

20. Initial thinking on how to build a suitable evidence base is progressing, and 
the Review looks forward to commenting on proposals once DWP and the 
representative groups have had more detailed discussions. It is hoped that 
work to build an evidence base will commence in early 2012. 



32 



An Independent Review of the Work Capability Assessment - year two 

Fluctuating conditions descriptors 

21 .The year one Review recognised the potential problems associated with 
assessing fluctuating conditions, particularly the repeatability of tasks, pain 
and fatigue and the view that the WCA provides a 'snapshot' assessment 
rather than taking a longer-term view of the condition and its impact on the 
individual. 10 As a result, the year one Review proposed that the descriptors 
used to assess fluctuating conditions were considered in more detail this 
year. 

Development of recommendations 

22. In January 201 1 a group led by the MS Society and also containing 
Arthritis Care, Crohn's and Colitis UK, Forward ME, the National AIDS 
Trust and Parkinson's UK were asked to provide recommendations on 
refining the approach used to assess fluctuating conditions in the WCA. 

23. They presented initial recommendations to an independent Scrutiny Group 
in April 201 1 . This Scrutiny Group comprised of: 

• Robert Moots (Chair), Professor of Rheumatology, University of 
Liverpool; 

• Steve Boorman, Medical Director, UK Occupational Health Services, 
Abermed; 

• Maurice Murphy, Consultant Physician, Clinical Academic Unit 
Director, Infection and Immunity, Barts and the London NHS Trust; and 

• Tom Sensky, Emeritus Professor of Psychological Medicine, Imperial 
College. 

24. In November 201 1 the Scrutiny Group and representative groups made 
joint recommendations to the Review. These recommendations: 

• Concluded that the descriptors need to be multi-dimensional, in 
particular taking into account frequency, severity and duration of 

symptom or symptoms; 



• 



Suggested that the descriptors should be clearly worded so that it is 
clear each activity must be able to be completed 'reliably, 
repeatedly and safely' and, as appropriate, 'within a reasonable 
amount of time'; 

• Attempted to include more work-related activities within the 
descriptors to give them more of a work focus; and 

• Proposed more consistent use of the non-functional descriptor 

by Decision Makers. 



10 



Chapter 5, paragraphs 31-32, ibid. 

33 



An Independent Review of the Work Capability Assessment - year two 

25. After considering these recommendations the Review was able to endorse 
them and submitted them to DWP later in November 201 1 . 

26. In doing so there was a recognition that, as there had not been enough 
time since the implementation of the March 2011 descriptors to develop a 
strong evidence base about their effectiveness there was a need to work 
with the Department to do so. Similarly, as they followed a similar model 
to the recommendations made for the mental, intellectual and cognitive 
descriptors, they would also potentially add to the complexity of the 
assessment. 

27. The recommendations from the representative groups and Scrutiny Group 
also suggested further work may be needed as part of future Independent 
Reviews on the specific wording of the sensory descriptors and that there 
may be a need to consider an additional descriptor which addresses the 
impact of generalised pain and/or fatigue. These issues will be considered 
in more detail early next year. 

28. Whilst DWP have not yet had time to consider the recommendations, the 
Review believes that there would be real value in this work joining up with 
the work which is being explored for the mental, intellectual and cognitive 
descriptors to build a suitable evidence base. The Review looks forward 
to the Department's response in due course. 

Cancer treatment 

29.Macmillan Cancer Support wrote to the Review in January 2011 outlining 
their concerns about the treatment of cancer patients receiving oral 
chemotherapy and some forms of radiotherapy. 

30. These concerns focused particularly on the way in which people receiving 
non-oral chemotherapy (and awaiting non-oral chemotherapy after the 
DWP internal review in March 2011) are exempt from the face-to-face 
assessment and are placed into the Support Group but people receiving 
oral chemotherapy and some forms of radiotherapy are not exempt from 
the face-to-face assessment. 

31. They argued that: 

"oral chemotherapy and radiotherapy can be just as debilitating as 
non-oral chemotherapy and can similarly affect a cancer patient's 
capability to work. " 

Development of recommendations 

32. Given the evidence presented by Macmillan and the recent advances in 
medical practice supporting this evidence Macmillan were asked to make 
recommendations for improving the provisions used for cancer patients 
receiving treatment for their condition. 



34 



An Independent Review of the Work Capability Assessment - year two 

33. To develop their recommendations and ensure they were clinically robust 
Macmillan carried out a consultation exercise with senior cancer 
specialists. They also consulted a wide range of national cancer charities 
on their proposals. 

34. The consultation exercise was carried out online and 14 experts 
participated from a range of different cancer specialisms, including 
healthcare representatives from other cancer charities. 

35. The consultation exercise comprised three phases: 

• Phase 1: involved setting questions about different forms of treatment, 
including chemotherapy, radiotherapy and emerging treatments and 
their side effects. 

• Phase 2: was an online 'bulletin board' that enabled respondents to 
interact with each other and see the responses posted by everyone 
to a series of questions. 

• Phase 3: agreed the final wording for recommended new provisions. 

36.Macmillan's findings were split between the various different types of 
cancer treatment available to patients. They concluded that: 

• Cancer patients receiving oral chemotherapy may experience equally 
as debilitating effects as patients receiving non-oral chemotherapy; 

• Cancer patients receiving radiotherapy for certain cancers are highly 
likely to experience significant debilitation as a result of their treatment; 
and 

• Undergoing radiotherapy in combination with chemotherapy is one of 
the most severely debilitating treatment regimes. 

37. In June 201 1 Macmillan made four recommendations for improving the 
cancer treatment provisions. These were: 

"A. As a result of the expert consultation we recommend that a cancer 
patient should be automatically exempt from going through the WCA 
and placed in the Support Group if they are: 

• Awaiting, receiving or recovering from treatment by way of 
intravenous, intraperitoneal or intrathecal chemotherapy; or 

• Awaiting, receiving or recovering from treatment by way of oral 
chemotherapy, except when the therapy is continuous for a period of 
more than six months; or 

• Awaiting, receiving or recovering from combined chemo-irradiation; or 



35 



An Independent Review of the Work Capability Assessment - year two 

• Awaiting, receiving or recovering from radiotherapy in the treatment 
of cancer in one or more of the following sites: 

Head and neck 

Brain 

Lung 

Gastro-intestinal 

Pelvic 

B. When cancer patients receive an ESA50 form for the first time they 
should be made aware of the need to provide supporting medical evidence 
from a relevant healthcare professional. 

C. Decision-makers should be better equipped and more empowered to 
use discretion appropriately when reviewing whether a cancer patient 
should be required to undertake the WCA following treatment. 

D. When a cancer patient's ESA Support Group status is being reviewed 
decision-makers should routinely carry out a "light-touch" 11 assessment 
seeking information regarding their treatment/post treatment condition 
before deciding whether or not to send out a further ESA50 form." 

38. The Reviewer considered Macmillan's recommendations and spoke to 
several cancer specialists. Given the evidence based nature of the 
recommendations - and the associated conclusion that the provisions 
need to change to incorporate a wider group of people who were likely to 
suffer similarly debilitating effects as a result of their treatment - the 
Review was able to endorse them without use of an independent Scrutiny 
Group. They were submitted to DWP for consideration in July 201 1 . 

Departmental response 

39. The Department agreed that Macmillan's report provided compelling 
evidence that the effects of oral chemotherapy can be as debilitating 
as other types of chemotherapy, and that certain types of radiotherapy 
(and in particular combined chemo-irradiation) can be just as debilitating 
if not more so than chemotherapy. 

40. Given this, there was agreement that the basis for the current provisions 
is no longer sound, especially given the evidence provided by Macmillan. 



11 Clarified with Macmillan to mean an assessment is carried out on the basis of evidence 
collected or provided by the claimant, rather than routinely sending out an ESA50 or calling 
the person for a face-to-face assessment. 



36 



An Independent Review of the Work Capability Assessment - year two 

41. There were some concerns, however, that allowing people undergoing the 
cancer treatments outlined in Macmillan's recommendations to go straight 
into the Support Group could have the unintended consequence of: 

• failing to recognise the variation in debilitation caused by the various 
types of treatment identified; 



• 



• 



removing the ability or chance for someone to work during their 
treatment (with suitable support from an employer) if they felt able to 
do so; and 

encouraging the wrong behaviours from employers and stigmatising 
cancer as something that can automatically lead to unemployment or 
worklessness, rather than encouraging employers to provide support 
to help individuals to stay in work where possible. 

42.Macmillan themselves recognise the value of work during cancer 
treatment, making it essential that the flexibility to work remains for 
an individual even when they are undergoing treatment for cancer: 

"Many people who are working when they are diagnosed with cancer 
would prefer to remain in work, or return to their job, during or after 
treatment." 12 

43. The Reviewer agreed with these reservations and so the Department 
undertook to consider the requirements for implementation of the 
provisions proposed by Macmillan whilst also ensuring that people 
undergoing cancer treatment are not automatically considered unfit 
for work. 

Current status 

44. The Department is currently working through the detail of any changes 
to the provisions. 

Real world test 

45. The year one Review heard a number of suggestions that the WCA could 
be improved by taking greater consideration of an individual's capability 
for work by providing some sort of 'real world' assessment of work 
capability. 13 

Development of recommendations 

46. In December 2010 the Review asked Citizens Advice Bureau to provide 
recommendations on what a real world test should or could look like. 



12 "Making It Work", Macmillan Cancer Support. 

13 Chapter 8, paragraphs 10-14, "An Independent Review of the Work Capability 
Assessment", Harrington, 2010. 

37 



An Independent Review of the Work Capability Assessment - year two 

47. They presented recommendations to the Review in July 201 1 . Rather than 
use an independent Scrutiny Group to iterate the proposals the intention 
was to host a seminar in the autumn for key stakeholder groups (TUC, 
CBI, Work Programme providers and representative groups) as well as 
Departmental officials. 

48. Citizens Advice Bureau's recommendations focused on: 

• A realistic assessment of ability to work; 

• Retention in Universal Credit (UC) of additional help for those able to 
do some work; 

• The trialling of a more diagnostic assessment; 

• Early collection and use of existing medical evidence for all ESA 

claimants; 

• Greater recognition of the effect of a deteriorating condition; 

• More sensitive timing of assessments; and 

• Recognition of the effect of combined impairments on ability to work. 

49. Unfortunately the full report was unable to offer clear, evidence based 
advice on what a real world test might look like. For example, the outline of 
a more diagnostic assessment lacked the necessary detail and evidence 
base; while the proposal for a more realistic assessment of ability for work 
lacked any information on what objective, measurable and fair criteria 
could be used to assess 'employability'. 

50. This meant that the Review was unable to commend the report to DWP. 
Instead a dialogue was maintained with Citizens Advice Bureau to try and 
find some practical suggestions that could be made to the Department. 

51. The planned seminar was cancelled, although the Review did meet the 
TUC and CBI to discuss the idea of a real world test in more detail, as well 
as arranging a seminar specifically for the Work Programme providers as 
part of the Call for Evidence. 14 

52. This series of meetings was helpful in identifying the need to separate 
'employability' from 'work capability' and the key role of DWP Operations 15 
and Work Programme providers in helping and supporting people into 
work after the WCA. 



14 These meetings also met recommendations in the Work and Pensions Select Committee 
report falling directly to the Review: page 39, paragraphs 121 and 122, 
http://www.publications.parliament.uk/pa/cm201 01 2/cmselect/cmworpen/1 01 5/1 01 502.htm 

15 From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 

38 



An Independent Review of the Work Capability Assessment - year two 

53. As identified in Chapter 7, communications need to improve in all parts of 
the WCA. Although it strays slightly beyond the remit of this Review, there 
is clearly a need for improved communications between Decision Makers 
and Work Programme providers if someone is found Fit for Work and 
volunteers for the Work Programme or is placed in the Work Related 
Activity Group. 

54. Work Programme providers described a situation whereby they know little 
about the person in front of them and how they have to go back several 
steps and essentially repeat a lot of the information gathered during the 
WCA. 

55. This is counter intuitive and is something that could and should be 

remedied. There is a clear need for improved information flows so that the 
Work Programme providers better understand why a decision has been 
reached and what limitations a person might have. They can then build on 
this with their local knowledge of the employment market and appropriate 
skills/employment related training. 

"We do not believe it is possible within the limited timeframe of the Work 
Capability Assessment to accurately assess all of the criteria necessary for 
a 'real work' test. We are also concerned that increasing the scope of the 
test may have a negative impact on the accuracy of outcomes", Ingeus UK 

"The one thing Papworth Trust would change to make the WCA operate 
more fairly and effectively is to improve its linkage with the Work 
Programme", Papworth Trust 

"Simulating a 'real world test' poses many challenges and there are a 
number of practical considerations... ERSA believes there are a number of 
more straightforward recommendations the review should consider which 
will improve the interaction between the WCA and the Work Programme", 
Employment Related Services Association (ERSA) 

Current status 

56. The Review welcomes the ongoing and constructive dialogue with Citizens 
Advice Bureau and will continue to work with them to explore some of their 
recommendations in more detail. 

Conclusions 

57. Whilst it may have taken longer than anticipated, real progress has been 
made in improving the descriptors. The cancer treatment provisions will 
hopefully change shortly to better reflect the impact of these treatments on 
individuals. Good progress is being made on adapting the ESA50 following 
recommendations on the mental, intellectual and cognitive descriptors and 
work is underway to establish how to build an evidence base to inform any 
future changes to the descriptors. The Review looks forward to receiving 
DWP's response on the fluctuating conditions descriptors 
recommendations. 

39 



An Independent Review of the Work Capability Assessment - year two 

58. The concept of a 'real world' test has proved more difficult to make both 
conceptually and operationally tangible. However, there may be elements 
of Citizen Advice Bureau's recommendations which the Review can 
explore in more detail and improving the 'baton pass' between the WCA 
and the Work Programme providers should aid clarity. 

59. Much has been made about the descriptors and changes to them, but it is 
important to see them as only one part (although an integral part) of the 
assessment. 

60. The criteria which are used to assess eligibility for ESA need to be right, 
but these changes also need to be seen in the context of other changes 
to the assessment which are already taking place such as the increase in 
Decision Maker autonomy, greater use of evidence from a chosen HCP 
and improved communication concerning the purpose of the assessment 
and the positive value of work for many people. 

61 . Making changes to the guidance and handbook used by Atos HCPs and 
the information available to DWP Decision Makers - which both groups 
use to help them better understand and interpret the descriptors - will 
also ensure a more accurate assessment, based on the latest medical 
evidence. The representative groups would be well placed to help with 
this process. 

"A number of organisations, including the National AIDS Trust, Arthritis 
Care, the National Rheumatoid Arthritis Society, Asthma UK, the Stroke 
Association and RSI Action, have identified inaccuracies and out-of-date 
information in the medical guidance provided to Atos assessors on certain 
conditions... We would welcome a more regular and transparent review 
and consultation process on this guidance to ensure that this remains 
accurate and up-to-date", Disability Benefits Consortium 

62. Testing of proposed changes to the descriptors will be helpful both in 
assessing whether they are better than the current ones and whether they 
will make the assessment fairer, more effective and more transparent. The 
Review welcomes the opportunity to work with DWP, the representative 
groups and the independent Scrutiny Group to do this for the mental, 
intellectual and cognitive descriptors. The Review hopes that the work 
on the fluctuating conditions descriptors will be included as part of this. 



40 



An Independent Review of the Work Capability Assessment - year two 

Recommendations 

Given my findings this year, I recommend that: 

A 'gold standard' review be carried out, beginning in early 2012. 
Future decisions about the mental, intellectual and cognitive 
descriptors should be based on the findings of this review. 

63. The 'gold standard' review should provide robust evidence on the way 
in which the current descriptors are working and test the proposed 
descriptors to see if they will improve the assessment. This will be an 
important step in establishing whether the proposed descriptors are more 
accurate than the current ones. This review needs to be thoroughly 
conducted and independently overseen to ensure fairness in the process: 
the Review looks forward to doing this and examining the results, but 
understands and advises that until then any further decisions about the 
mental, intellectual and cognitive descriptors should be put on hold. 

64. Similarly, if, as hoped, the fluctuating conditions descriptors work is 
included in this 'gold standard' review then decisions about those should 
only be taken once that work is completed. 

65. If changes to the descriptors are made, much of their success will depend 
on how Atos HCPs carry out the assessment. Therefore, HCPs will need 
to be trained to enable them to effectively utilise the revised ESA50 form 
and any new descriptors. 

DWP should consider working with relevant representative groups 
and their clinical advisers to: 

• Update the handbook and guidance used by Atos healthcare 
professionals; and 

• Produce practical guidance for Decision Makers. 

66. Representative groups have raised a number of concerns about the 
handbook and guidance used by Atos HCPs and the guidance available 
to DWP Decision Makers. Whether the ESA50 and descriptors change or 
not, it is imperative that the information available to both of these groups 
is both up to date and accurate. 

67. As and when these materials are being updated it would appear sensible 
to involve the representative groups and their clinical advisers so that 
there is a common understanding of the information used and its validity. 

This 'bottom up' model - involving a wide range of experts as well 
as DWP - should also be adopted in any future changes to the WCA 
descriptors, where appropriate. 



41 



An Independent Review of the Work Capability Assessment - year two 

Work on the specific wording of the sensory descriptors and an 
additional descriptor which addresses the impact of generalised 
pain and/or fatigue should be considered early on in the year three 
Review. 

68. The model used for making recommendations for refinements and 

improvements to the descriptors has proved valuable in providing practical 
recommendations for improving the WCA. 

69. The use of experts from outside of DWP has proved particularly valuable, 
and there is a strong case for making use of the expertise of the relevant 
representative groups and clinical experts should this process be 
repeated. This approach has the advantage of involving those who best 
know some of the practical problems with the assessment, whilst also 
making use of both independent experts and people within the Department 
who have most knowledge about how the WCA is implemented to ensure 
a robust and iterative process. 

70. The report on the fluctuating conditions descriptors highlighted that there 
may be further value in repeating the process for sensory conditions and 
to see if generalised pain and/or fatigue are worthy of a separate 
descriptor to ensure that the process of continuous improvement to the 
WCA is maintained. 

71 .The ultimate aim should be to ensure that the assessment is as fair and 
accurate as is possible, and replicating this process for these conditions 
will help ensure this happens. 

As and when changes to the descriptors are made, DWP and other 
relevant experts should monitor the impact of these changes to 
ensure both that they are working and that they are not causing any 
unintended consequences. 

72. If changes are made to the descriptors it is important to understand the 
impact that these changes are having, and to ensure that the changes are 
having the impact envisaged. 

DWP consider ways of sharing outcomes of the WCA with Work 
Programme providers to ensure a smoother claimant journey. 

73. This practical step will improve the claimant experience for people placed 
in the Work Related Activity Group and for people found Fit for Work who 
volunteer onto the Work Programme, ensuring that 'employability' as well 
as work capability are properly considered. 

74. Similar provisions may also be helpful for Work Choice providers who are 
likely to face similar 'communication gaps' with DWP Decision Makers. 



42 



An Independent Review of the Work Capability Assessment - year two 

Chapter 4: Research 

i) Year one recommendation - quality decision making 

1 . In year two the Review should examine what happens to people who are 
found Fit for Work, people who are placed in the Work Related Activity 
Group, and people who are placed in the Support Group. 

Background 

2. It is important to understand exactly how decisions about eligibility for 
Employment and Support Allowance (ESA) have been made before 
considering in more detail what happens to these people after the 
decision. Department for Work and Pensions (DWP) Decision Makers play 
a key role in this process, particularly in identifying and allocating claims 
which may be on the borderlines between either being found Fit for Work 
and the Work Related Activity Group or the Work Related Activity Group 
and the Support Group. 

3. Research was therefore commissioned to understand better why a case 
might be seen by DWP Decision Makers as borderline and to develop 
guidance to support future decision making. 

Decision Maker focus groups 

Approach 

4. Ten focus groups were conducted across a range of Benefit Delivery 
Centres. At each Centre there was one focus group for more experienced 
Decision Makers and one for Decision Makers newer to the role. 

5. Focus groups aimed to explore broad views and approaches with Decision 
Makers, as well as capturing detailed feedback on specific scenarios 
where a claim could be considered borderline. 

Findings and conclusions 

6. The research report relating to this work will be published in January 2012. 
Therefore further analysis will be carried out once its conclusions are 
finalised. 

7. The research suggests that local practices vary considerably between 
Benefit Delivery Centres and between individual Decision Makers. This 
emphasises the need for professional standards to ensure the consistency 
and quality of decision making. 



43 



An Independent Review of the Work Capability Assessment - year two 

8. The research has also highlighted some potential process issues in terms 
of how Decision Makers treat claims. For example, none of the Benefit 
Delivery Centres where focus groups were conducted had a separate and 
specific approach to arguably borderline cases, and while in some Benefit 
Delivery Centres Decision Makers feel empowered to award points, in 
others the Decision Makers believe they have to go back to Atos in all 
cases where they want to change Atos's recommendation. 

9. Interviews with Atos healthcare professionals have also been carried out 
but were not included in the interim findings. The Review looks forward to 
exploring these in more detail once they are published. 

Conclusions 

10. Research into how and why Decision Makers make decisions - and the 
processes they use to do this - has revealed some interesting findings. 

11. Consistency and quality of decision making appear to be key issues, 
especially considering the increased importance of their role following the 
year one Review's recommendations. 

12. The Review looks forward to receiving the full research report in January 
and to discussing the findings in more detail with DWP to address potential 
issues highlighted by the research. 

Recommendations 

On the basis of the evidence presented in the interim findings I 
recommend that: 

DWP undertake regular audit of Decision Maker performance. 

13. The process used in this research could easily be modified to constitute 
a formal audit of DWP Decision Maker performance. Atos healthcare 
professionals (HCPs) are regularly audited to ensure consistency of 
performance (see Chapter 5), but it is important that a similar system is put 
in place for Decision Makers to ensure that quality standards of decision 
making remain high. 

14. The introduction of a Quality Assessment Framework for DWP Decision 
Makers is a welcome step. However given the increased emphasis on the 
Decision Maker's role it is important to ensure that they are making sound 
decisions that are free of bias and unnecessarily influenced by empathy, 
but that are evidence based and in accordance with the law. 

15. Introducing a regular and robust audit of DWP Decision Maker 
performance would ensure this happens. Northern Ireland appear to have 
a good process for Decision Maker audit, and there may be useful lessons 
to learn here. 



44 



An Independent Review of the Work Capability Assessment - year two 

In year three, further research is undertaken to examine in more 
detail what happens to people found Fit for Work and people placed 
in the Work Related Activity (including Work Programme outcomes) 
and Support Groups, and the factors influencing these outcomes. 

16. The Review continues to believe that undertaking more general research 
into outcomes by Group would be a helpful exercise. This should form part 
of the year three work programme. 



ii) Year one recommendation - withdrawn claims 

17. In year two the Review should examine what happens to people who do 
not complete their Work Capability Assessment (WCA). 

Background 

18. In year one the Review identified that over 36 per cent of Employment and 
Support Allowance (ESA) claims were closed or withdrawn before the 
claimant had an Atos face-to-face assessment. 

19. Anecdotal evidence suggested that most of these people returned to the 
labour market, but it was felt important to have more precise data in case 
a significant group of these claimants were withdrawing their claim and 
being lost to the system for other reasons, particularly if these reasons 
were to do with the WCA process. 

Results 

20. Recent research 16 confirms that 71 per cent of people whose claim was 
closed or withdrawn were either in employment or self-employment or 
were unemployed and looking for work six to nine months after their initial 
ESA claim. Most of the remainder were either sick (temporarily or 
permanently) or caring for family members. 

21.DWP analysis has supplied more detail about people who withdrew their 
claim or whose claim was closed, and the reasons for this 17 . Thirty-one 
per cent reported that they had withdrawn their claim, 30 percent that their 
claim had been closed, and nearly a quarter (23 percent) said they had 
been claiming ESA but were now back in work. 



16 



"Employment and Support Allowance: Findings from a face-to-face survey of customers. 



DWP Research Report No 707", Barnes, Sissons and Stevens, 2010. 
17 Based on DWP in-house secondary analysis of "Routes on to ESA" survey. For published 
analysis of the survey, see "Employment and Support Allowance: Findings from a face-to-face 
survey of customers. DWP Research Report No 707", Barnes, Sissons and Stevens, 2010. 

45 



An Independent Review of the Work Capability Assessment - year two 

22. Of the 31 per cent who had actively withdrawn their claim and given a 
reason for doing so 18 : 

• 47 per cent had withdrawn their claim because they became fit for 
work, were found Fit for Work or were claiming Jobseeker's Allowance 
(JSA); 

• 27 per cent had withdrawn because they went back to work or got a 
job; and 

• 8 per cent had withdrawn because they found the process too stressful 
or bureaucratic. 

23. Claims from men represent 60 per cent of all closed/withdrawn claims, and 
this gender split is broadly similar across the other ESA outcome groups. 
However, those whose claim was withdrawn or closed are more likely to 
be younger compared to the other outcome groups. 

24. Claimants whose claim was withdrawn or closed are less likely than those 
in other outcome groups to have multiple health conditions (54 per cent, 
compared to 67-69 per cent); and those with a health condition in the 
closed/withdrawn group were more likely to have a fluctuating condition 
(60 per cent), compared to those with a health condition in the other 
outcome groups (33-51 per cent). 

25. In common with claimants found Fit for Work and in the Work Related 
Activity Group, those in the closed/withdrawn group were more likely 
to have a musculoskeletal condition than a mental health or systemic 
condition. 

Conclusions 

26. Most people who withdrew their claim did so because they no longer 
needed ESA. 

27. There does not seem to be a significant group of claimants who were 
unjustifiably or inappropriately lost to the system. 

28. Whilst a relatively small number of people who made an initial claim for 
ESA but later withdrew it did so because the process was too complicated 
or stressful, it is hoped and expected that the added contact with claimants 
resulting from the year one recommendations (particularly telephone calls 
to explain the process to them) should result in a more empathetic and 
transparent system which will help reduce this figure. 



18 Some people may have given multiple answers to the question. 

46 



An Independent Review of the Work Capability Assessment - year two 

Chapter 5: Atos Healthcare 

i) Year one recommendation - Logic Integrated 
Medical Assessment (LiMA) 

1 . In year two the Review should examine the Atos computer system (LiMA) 
and how it can drive the right behaviours. 

Background 

2. Atos healthcare professionals (HCPs) use the LiMA computer system to 
help structure discussions at the face-to-face assessment, to build a 
picture of the claimants functional capabilities and to generate a final 
report containing findings, advice and recommendations to Department 
for Work and Pensions (DWP) Decision Makers. 

3. The first Review received a number of negative comments about LiMA 
and the impact it can have on both the conducting of the face-to-face 
assessment and the quality of the reports generated about individual 
claimants. Generally speaking, there was a view that LiMA can potentially: 

• drive HCP behaviours; 

• drive HCP decisions, with HCPs only ticking boxes and LiMA driving 
the conclusions; and 

• mean an impersonal and mechanistic assessment as the HCP is 
forced to look at the computer screen rather than the claimant. 

4. An independent assessment as to whether or not LiMA drives HCP 
behaviours, and if so whether it drives the right/positive behaviours, 
was therefore undertaken. 

Findings 

5. The Review had the chance to see the LiMA system on several occasions 
(in a training environment and in real and mock face-to-face assessments) 
as well as having the opportunity to speak to key HCPs in Atos about it 
and how it has been developed. 

6. As part of the continual process of improving LiMA and in implementing 
DWP's internal review of the WCA and the changes from the first 
Independent Review considerable changes have been made to the 
system in the last year. 

7. These changes, particularly the insertion of increased options for HCPs 
to select around variability of condition, appear to have improved the 
software. 



47 



An Independent Review of the Work Capability Assessment - year two 

8. Having looked at this in some detail it appears that the 'logic' of the system 
is sound, and that it points the HCP in a certain direction whilst flagging 
linked elements (e.g. if someone has a mental health condition, all relevant 
areas will be highlighted) but does this in a constructive rather than 
restrictive way. There are no phrases which the HCP must use, and all 
actions are completed by the HCP rather than the software. 

9. Similarly there are no mandatory questions in LiMA. It provides a guide 
and structure for the HCP undertaking the face-to-face assessment, but 
does not direct the assessments. HCPs remain in control of the system at 
all times, and anything appearing on the final report (the ESA85) is a result 
of information they have input. 

10. However it does appear that the use of free text within LiMA is key to 
individualising the assessment. Although Atos are placing an increased 
emphasis on the use of free text, and the use of the new personalised 
summary statement 19 should help further, it is important for Atos to monitor 
the use of free text to ensure that reports actually reflect the individuals 
they have seen. 

11. A strong emphasis is placed on being able to justify conclusions during 
Atos HCP training and again use of free text will help HCPs do this by 
individualising the assessment for each claimant. 

12. There may be a need for Atos to monitor the 'softer' skills of their HCPs, 
as well as auditing their disability analysis competence. 

13. Atos already reinforce the importance of 'soft skills' during new entrant 
training, regularly monitor the manner adopted by HCPs during the 
Customer Satisfaction Survey and have introduced a bespoke 'soft skills' 
training DVD to emphasise the importance of interactions with the 
claimant. But if HCPs do not have the necessary IT (especially typing) or 
communication skills then using LiMA could distract their interaction with 
the claimant. This could potentially lead to an impersonal and mechanistic 
assessment. 

14. The first Review was clear that there was a need for a consistent and 
replicable assessment, and having a computer assisted assessment would 
seem to be the most sensible way of achieving this. The reassessment 
of Incapacity Benefit claimants strengthens the need for consistency of 
assessments as the number of face-to-face assessments each week has 
already increased significantly. 

15. However, the need to do more assessments and the desire to have an 
assessment which is replicable across the country should not mean that 
the quality of assessments drops or the way in which assessments are 
conducted suffers. 



19 Chapter 5, paragraphs 43-44, "An Independent Review of the Work Capability 
Assessment", Harrington, 2010 

48 



An Independent Review of the Work Capability Assessment - year two 

Stakeholder seminars and Call for Evidence 

16. Since the Independent Review process started a number of concerns have 
been raised by stakeholders about LiMA, what it does/does not do, how it 
drives HCP behaviours and its impact on the assessment. However, in 
recognition that many people have never had an opportunity to see the 
system in operation three seminars were organised for key stakeholders 

to do this. A specific question about LiMA was also included in the Call 
for Evidence. 

Before the seminars 

17. Prior to attending the seminars stakeholders were asked to fill in a 
questionnaire detailing their current knowledge of the LiMA system and 
its role within the face-to-face assessment. 

18. Views in these questionnaires varied considerably, for example 20 : 



• 



• 



Answers to: 'On a scale of one (know nothing) to ten (very 
knowledgeable), how much do you know about LiMA, what it does and 
how it works?' ranged from two to eight, with an average of 4.5. 

"Most of my knowledge about LiMA is inferred from what people have 
told us about their WCAs. It has been suggested to me, by people with 
more experience of this issue, that the system guides the assessor in 
terms of identifying areas they should seek information. From people's 
experience of assessments it would appear that HCPs feel as though 
they need to stick to a fairly rigid format and structure and it would 
seem likely that the information required by LiMA is the basis of this", 
Mind 

Answers to: 'On a scale of one to ten, how much do you think that the 
logic of LiMA pre-determines questions and extrapolates answers 
based on responses to earlier questions?' where one was 'Not at all' 
and ten was 'Completely' ranged from four to ten, with an average 
of 7.2. 

"This certainly used to happen with Incapacity Benefit, where the same 
statement taken from the record of daily life would crop up all over the 
place even where it was quite incongruous", SSAC 

Answers to: 'Given that it is important to document the information 
given by the customer contemporaneously during the assessment, 
where do you think the balance of interaction lies between gathering 
information using a computer system in a consistent manner and 
healthcare professional interaction/rapport with the customer?' where 
one was 'Using a computer system' and ten was 'HCP interaction' 
answers ranged from two to ten, with an average of 6.9. 



20 



The Review recognises and acknowledges the small sample sizes used. 

49 



An Independent Review of the Work Capability Assessment - year two 

"The computer should be for recording the assessment - nothing 
more", National Autistic Society 

The seminars 

19. At the seminars themselves there appeared to be a fundamental mis- 
understanding amongst some stakeholders of the role LiMA plays in the 
face-to-face assessment. 

20. This manifested itself in comments and criticisms about how the 
assessments are carried out by the HCP rather than about the way in 
which LiMA was used. 

21 . However several anomalies in the content of and language used in LiMA 
were identified by the stakeholders, including: 

• The lack of an option to record that the claimant has a Certificate of 
Visual Impairment, which has been updated as a result of the 
seminars. 

• Whether the phrasing of the 'I advise a return to work could be 
considered within...' option needs revising in light of the fact some 
claimants may never have worked before. 

• Whether the phrasing of the 'Client states...' option needs revising in 
light of the fact some claimants may have someone with them at the 
assessment who is answering on their behalf. 

22. There were also a number of other comments, including: 



• 



that LiMA should have a section focusing on work as well as the typical 
day section; and 

• that LiMA could create sentences such as "can walk to bus stop, 
despite pain relating to neuropathy and fatigue which lasts for some 
hours afterwards" where the word 'despite' has a meaning quite distinct 
from what the patient could have said in the situation as the pain and 
fatigue could be caused by the walking. 

23. The point about LiMA focusing on work is intrinsically linked to the 
descriptors, and indeed the policy supporting the WCA. Whilst there is 
a risk of fundamentally changing the policy basis for the WCA - some 
people may never have worked and so the descriptors would not apply to 
them, for example - this is something that has been recommended as part 
of the work looking at the fluctuating conditions descriptors and should 
be considered as part of that by DWP as the recommendations are 
considered in detail (see Chapter 3). 



50 



An Independent Review of the Work Capability Assessment - year two 

24. Observations about LiMA created words and sentences have some merit. 
But with the move towards an emphasis on HCPs using free text 
accurately to record the face-to-face assessment it would be wrong to 
suggest changes being made to LiMA which (although correcting some 
factual anomalies) could have the perverse incentive of making it easier 
for HCPs to use the stock phrases within LiMA. 

25. On balance the Review believes that the emphasis should be on HCPs - 
and the training and auditing of them - to interpret what the claimant says 
and input this into LiMA correctly, rather than allowing all possible 
combinations of claimant answers to be covered in the system. This, of 
course, does not mean that the accuracy of assessments and subsequent 
reports should suffer, but that HCP quality should ensure the report 
reflects the conversation had at the assessment. 

After the seminars 

26. Questionnaires after the seminars showed a similar range of views as the 
pre-seminar questionnaires, with some views on LiMA having changed 
considerably (either positively or negatively) and some having stayed the 
same. 

"/ was left with the impression that the way the LiMA system currently 
operates does allow for serious errors of judgement to be made in relation 
to assessing whether someone is going to be fit for work", Forward ME 

27. As identified during the seminars, many of the comments focused on how 
the assessments were conducted and other more general policy issues, 
rather than the use of the LiMA software during the assessment. 

"Although the provision of free text boxes throughout the assessment is 
good I think the concern remains that time and volume pressures mean 
many HCPs will rely on those options provided by LiMA", Leonard 
Cheshire Disability 

28. But there was a general consensus that HCP quality was key to how LiMA 
is used as well as to the quality of the assessment itself. 

"/ think that LiMA is potentially an excellent system; my concern is that 
it only reaches it potential in the hands of [the right] people", SSAC 

29. Comparing views to some of the questions asked before and after the 
seminars: 21 

• Average answers to: 'On a scale of one (know nothing) to ten (very 
knowledgeable), how much do you know about LiMA, what it does 
and how it works?' increased from 4.5 to 7.6. 



21 The Review recognises and acknowledges the small sample sizes used, and that not 
all stakeholders answered both questionnaires. 

51 



An Independent Review of the Work Capability Assessment - year two 

"I think the seminar gave a useful level of information about LiMA, it did 
succeed in demystifying it", National Autistic Society 

• Average answers to: 'On a scale of one to ten, how much do you think 
that the logic of LiMA pre-determines questions and extrapolates 
answers based on responses to earlier questions?' where one was 
'Not at all' and ten was 'Completely' reduced from 7.2 to 5.8, although 
there was still considerable variation in answers. 

"The seminar did clarify that LiMA does not predetermine what 
questions should be asked", National Autistic Society 



• 



Average answers to: 'Given that it is important to document the 
information given by the customer contemporaneously during the 
assessment, where do you think the balance of interaction lies between 
gathering information using a computer system in a consistent manner 
and healthcare professional interaction/rapport with the customer?' 
where one was 'Using a computer system' and ten was 'HCP 
interaction' changed from 6.9 to 5.5, although again there was 
considerable variation in answers. 

"After the seminar I am still of the view that the system should be 
influenced much more by the HCP interactions with the claimant than 
by the computer", RSI Action 

Call for Evidence 

30. Views expressed in the Call for Evidence mirrored those expressed by 
stakeholders who attended the seminars. 

"From our own observations, it appears that LiMA drives the process 
rather than the HCP being in control of LiMA. The fact that the programme 
autopopulates the ESA85 causes any errors to misinform the report", 
Bath CAB 

"LiMA cannot read free text; it looks for key words e.g. usually, sometimes, 
rarely and for set phrases e.g. can walk 10 minutes and it disregards the 
rest. The operators have to deliberately change what the claimant has said 
to fit in with the set pieces to try and get LiMA to provide them with advice 
on appropriate descriptors and to help them construct the justification", 
MsP 



52 



An Independent Review of the Work Capability Assessment - year two 

31 .Given the specific question about LiMA in the Call for Evidence these 
views were expressed both more frequently and more vociferously than 
during the year one Review. Claimants not recognising themselves in the 
ESA85 report and factual inaccuracies in the report seem to be particularly 
problematic in this respect. 

"Following receipt of my 31 page Atos report, a number of issues 
concerning quality of report and findings were evident", Mr K 

"There seems to be some problems with the assessors being very slow 
to enter the data on the system which makes an often stressful interview 
very long", Cymorth Cymru 

32. Again, many of the concerns appear to be based on the way in which the 
assessment itself is carried out by HCPs or the fundamental basis of the 
assessment where there is not a focus on the working day. 

33. The Call for Evidence, therefore, was extremely helpful in emphasising the 
recurring themes and strength of feelings about what LiMA does or does 
not do whether these were explicitly linked to the actual software or not. 

Conclusions 

34. The Review welcomes the positive changes made to LiMA as part of the 
continual process of improving it. Although some minor changes might 
further improve LiMA there does not appear to be any fundamental 
problems with the way in which the software operates. 

35. Any issues or concerns expressed by stakeholders and Call for Evidence 
respondents about LiMA appear to relate more to the way in which HCPs 
carry out assessments or use the software, rather than the software itself. 

36. Many of the comments received about LiMA and what it does/does not do 
appear not to be robust or evidence based. The Review has seen no 
evidence that LiMA: 



• 



• 



drives HCP behaviours by forcing the face-to-face assessment down 
a certain path; 

drives HCP decisions about what appears in the final report; and 

leads to an impersonal and mechanistic assessment where the HCP 
has to focus on the computer screen rather than the claimant. 



53 



An Independent Review of the Work Capability Assessment - year two 

37. The important caveat to all of this is that LiMA relies on the quality of 
information which is put into it, and so the quality of assessment carried 
out by the HCP. Failure to put adequate information into LiMA is likely 
to lead to a final report which does not adequately reflect the individual 
claimant, and vice-versa. 

38.Atos are rightly encouraging HCPs to use more free text in their 

assessments, and this (along with the personalised summary statement) 
will help better reflect individual claimants. But there is no evidence that 
LiMA in itself drives either positive or negative behaviours as the face-to- 
face assessment is being carried out. 

Recommendations 

Based on my review of LiMA I recommend that: 

39. The stakeholder seminars identified several anomalies in the language 
used in LiMA which could have a negative impact on the quality of reports 
generated during the face-to-face assessment (see paragraph 21). 

These changes should be adopted, and that further changes to LiMA 
should be considered as and when they are raised. 

40.Atos are encouraging the use of free text within LiMA to ensure what the 
reports generated are of high quality and accurately reflect individual 
claimants. 

41. Given this increased emphasis on the use of free text it will be important 
both to monitor the impact of this and to ensure the HCPs have the skills 
to use suitable and accurate amounts of free text whilst at the same time 
engaging appropriately with the claimant. 

Atos and DWP monitor and audit the use of free text within LiMA to 
ensure a consistently high standard of accurate reports. 

If needed, Atos healthcare professionals are provided with the 
relevant IT training - especially typing - to enable them to use the 
LiMA system intelligently and ensure that the quality of the face-to- 
face assessment does not suffer. 



54 



An Independent Review of the Work Capability Assessment - year two 

ii) Year one recommendation - Consistency of Atos 
healthcare professional performance 

42. In year two the Review should explore the use of other healthcare 
professionals in the Atos assessments and check the consistency of 
assessments by different professions. 

Background 

43. Atos contracts doctors, nurses and physiotherapists to undertake the 
face-to-face assessment part of the WCA for the Department for Work 
and Pensions (DWP). 

44. At the end of May 201 1 Atos contracted 665 healthcare professionals 
(HCPs), with the following numbers in each category: 

• 231 doctors (35%) 

• 379 nurses (57%) 

• 55 physiotherapists (8%) 

45. The first Review looked at the recruitment of HCPs to Atos 22 , whilst the 
training provided to new recruits has been considered in more detail this 
year (see Chapter 6). 

Consistency of healthcare professional performance 

46. To explore whether the current mix of HCPs is right - and whether there 
is consistency between the different HCPs - the review considered data 
available from Atos about outcome recommendations (scores of 15 points 
or more) split by HCP group. 

47. The sample used was of just under 34,000 cases. The results are in 
Table 2. 



22 Chapter 5, paragraph 1 0, "An Independent Review of the Work Capability Assessment" 
Harrington, 2010. 

55 



An Independent Review of the Work Capability Assessment - year two 



Table 2: 15 point or more recommendations by HCP type 








Doctors 


Nurses 


Physiotherapists 


Total 


Total cases 


11,670 




20,720 




1,420 




33,810 




Over 15 points 


2,450 


21% 


3,670 


18% 


250 


18% 


6,370 


19% 


Uncontrolled condition 


30 


0% 


30 


0% 





0% 


60 


0% 


Chemotherapy 
Support Group 


20 


0% 


50 


0% 





0% 


70 


0% 


Terminal Illness 
Support Group 


10 


0% 





0% 





0% 


10 


0% 


Severe Functional 
Disability Support 
Group 


720 


6% 


1,180 


6% 


50 


4% 


1,950 


6% 


Pregnancy Support 
Group 


10 


0% 


20 


0% 





0% 


30 


0% 


Physical or Mental 
Health Risk Support 
Group 


300 


3% 


730 


4% 


30 


2% 


1,060 


3% 



48. The results show broadly consistent findings between HCP groups. 
Understandably doctors make more recommendations of 15 points or over 
as they assess the majority of complex cases which are more likely to 
result in a recommendation of being allowed ESA. Given the sample size 
of the physiotherapist group it should also be noted that their outcomes 
are likely to be more dependent on the characteristics of the sample seen 
during the month. 

49. The consistency of these findings would suggest that Atos's training and 
audit of HCPs is having the desired outcome and that, regardless of 
profession, face-to-face assessments are being undertaken in a reliable 
manner. 



23 



Numbers rounded to the nearest 10. 



56 



An Independent Review of the Work Capability Assessment - year two 

Differences between physical health conditions and 
mental health conditions 

50.Atos also collect information about whether HCPs recommend points for 
each claimant for physical issues or mental function issues. The results by 
HCP type are in Table 3: 

Table 3: Recommended point scores for physical and mental health by 
HCP type 24 





Doctors 


Nurses 


Physiotherapists 


Total 


Total cases 


11,670 




20,720 




1,420 




33,810 




6 points - physical 


900 


8% 


1,300 


6% 


140 


10% 


2,340 


7% 


9 points - physical 


300 


3% 


470 


2% 


30 


2% 


800 


2% 


>15 points - physical 


1,080 


9% 


1,490 


7% 


110 


8% 


2,680 


8% 


Awarded any points - 
physical 


2,280 


20% 


3,260 


16% 


280 


20% 


5,820 


17% 




















6 points- mental 
function 


530 


5% 


940 


5% 


60 


4% 


1,530 


5% 


9 points - mental 
function 


220 


2% 


410 


2% 


20 


1% 


650 


2% 


>15 points- mental 
function 


1,250 


11% 


2,070 


10% 


130 


9% 


3,450 


10% 


Awarded any points - 
mental function 


2,000 


17% 


3,420 


17% 


210 


15% 


5,630 


17% 




















Awarded any points - 
all 


4,280 


37% 


6,680 


32% 


490 


35% 


11,450 


34% 



51 . Atos do not identify a primary condition in their assessments, but this 
information is helpful in showing the split between 6 point, 9 point and 
15 or more point recommendations by HCP type. 



24 



Numbers rounded to the nearest 10. 



57 



An Independent Review of the Work Capability Assessment - year two 

52. As with the 15 point or more recommendations there appears to be broad 
consistency between HCP types. Nurses are slightly less likely to 
recommend points against physical health descriptors and 
physiotherapists are slightly less likely to recommend points against 
mental function descriptors. It is important to continue to monitor this 

to see if all HCP types assessing all conditions remains appropriate. 

53. Doctors are more likely to recommend points against any of the 
descriptors, although (as with the 15 point or more recommendations) 
given they are more likely to be assigned complex cases -which by 
definition are more likely to score points - this is to be expected. 

54. It is worth noting that, whilst these figures are helpful in giving an indication 
of Atos HCP recommendations, they will not correspond to the overall ESA 
disallowance rate. This is because: 

• these are only Atos recommendations and may not translate to 
Decision Maker decisions; 

• this is a much smaller sample than the national data; and 

• claimants will score across both physical and mental function 
descriptors to reach 15 or more points. 

Audit by healthcare professional group 

55. As identified in the first year Review, Atos continue to regularly monitor 
and audit check the quality of HCPs. As the first year Review made clear, 
A-grades are given if the assessment fully meets required standards; 
B-grades are where some improvements are possible; and C-grades are 
given where the report is deemed to be unacceptable and it does not meet 
required standards. 25 

56. In the three months to the end of May 201 1 Atos audited just under 
1,000 cases. 

57. The results of these audits are shown in Figure 2. 



25 Chapter 5, paragraphs 1 2-1 5, "An Independent Review of the Work Capability 
Assessment", Harrington, 2010. 

58 



An Independent Review of the Work Capability Assessment - year two 
Figure 2: Grading of assessments post-audit by HCP type 



O 



u 




0. 





J All practitioners 

| Doctors 

! 1 Nurses 

; I Physios 



A-grade 



B-grade 
Grade 



C-grade 



58. The per cent of C-grade assessments has fallen when compared to 
a comparable number of assessments quoted in the first year review 
(3.1 per cent in 2011 compared to 5 per cent in 2010). Whilst recognising 
that the sample will depend on the types of cases chosen for audit as 
well as the quality of HCPs this does suggest that standards at Atos 
remain high - and DWP's less than 5 per cent target for C-grades is 
still being met. 

59. All Atos HCPs are audited by the same group of auditors and to the same 
audit criteria, regardless of the type of HCP. The Review spent time at the 
Atos Independent Audit Assurance Panel in Bristol reviewing the auditing 
of the auditors. This work was done by senior Atos HCPs from another 
region and involved DWP staff monitoring the process. The process seen 
was thorough and the results of any shortcomings were reported to the 
individual auditor. General lessons were transmitted to all Atos auditors. 

60. It appears that the audit results by grade are broadly comparable across 
HCP type. There is little appreciable difference between HCP groups at a 
national level where C-grades are concerned, whilst the fact doctors have 
proportionately more B-grades (and so proportionally less A-grades) than 
nurses or physiotherapists is likely to reflect that they see the more 
complex doctor only cases and therefore auditors are more likely to 

pick up learning points which will be fed-back through B-grade audits. 

61 .The proportion of B-grade reports should not be seen as negative, or be 
used to suggest that HCPs are below the expected quality standards. 
Rather this reflects a conscious effort by Atos to constantly monitor and 
improve HCP performance, and B-grade reports are contractually fit for 
purpose. This is to be commended. 



59 



An Independent Review of the Work Capability Assessment - year two 

Conclusions 

62. The data provided by Atos suggests that there is not a significant 
consistency issue between the three types of HCPs who carry out 
face-to-face assessments either in terms of recommendations for 
claimants scoring 15 or more points or recommendations for where 
points are scored. 

63. Taking this, the training provided to new recruits to Atos (see Chapter 6) 
and the audit procedures in place into account it would appear that 
continuing negative responses to the face-to-face assessment - 
particularly about the way in which the assessment was conducted - are 
related to isolated individuals rather than there being an endemic issue 
within Atos. This, of course, does not mean that these negative 
experiences should be ignored. 

64. It is beyond the remit of this Review to make recommendations about who 
should be carrying out the assessments (as opposed to reviewing how 
they are carried out). Whilst there appears to be a good level of 
consistency between the types of HCP currently used by Atos, the Review 
has also considered whether any other types of HCP could carry out 
WCAs. 

65. The Review has heard from several people that Occupational Therapists 
(OTs) might be well placed to carry out WCAs given their expertise in 
assessing functional capability for work. Similarly, several people have 
suggested that only people with relevant mental health expertise should 
carry out assessments for people with a mental health condition. 

66. If OTs, or other types of HCP, were to carry out WCAs it would be 
important that they were subject to the same training and quality 
standards as other HCPs currently employed by Atos. 

Recommendations 

Based on the data presented by Atos and my analysis of this I recommend 
that: 

Given the importance of the quality of assessments (especially 
with Incapacity Benefit reassessment fully underway) DWP should 
consider tightening the target for C-grade reports. 

67. Evidence supplied to both the first and second Reviews suggests that Atos 
are regularly meeting the 5 per cent C-grade target. Whilst it is necessary 
for the C-grade target to exist to ensure that HCPs can learn from 
experience, this target could be more challenging and should not be 

a 'safety net' which supports poor performance. 

To improve the transparency of the face-to-face assessment, data on 
Atos performance and quality should be regularly published. 



60 



An Independent Review of the Work Capability Assessment - year two 

68. The Review is impressed with the consistency of HCP performance. 
However, it is important to ensure that standards are not allowed to slip 
and so regular reporting of Atos performance and quality should become 
standard. 



iii) Call for Evidence responses 

69. This year's Call for Evidence asked a number of specific questions about 
the face-to-face assessment. 

70. The Review recognises that there are still a considerable number of 
negative comments about the face-to-face assessment and the HCPs 
carrying out those assessments. The Call for Evidence was enlightening 
in eliciting these views from individuals. 

71 .The Call for Evidence asked specifically about where concerns with the 
face-to-face assessment focused. The vast majority of respondents had 
concerns with the HCPs approach, their understanding of conditions and 
the IT supporting the assessment; or with the HCP's approach and 
knowledge. 

72. It is worrying that these negative experiences of the face-to-face 

assessment, and the WCA process as a whole, are still being reported to 
the Review. Of particular concerns are: 

• Reports that supporting evidence from a chosen healthcare adviser is 
not being asked for or taken into consideration in the decision making 
process. 

"The decision appears to have been made only on the medical and the 
detailed form I filled in has no weight. There is much evidence available 
from my doctor, specialists, and work experience that in the last few 
years that I have tried to work, am able to do part time work for a short 
period but then my symptoms flare up and I am incapable of work, 
amounting to about 6 months in a year. I was not asked to provide this 
back up evidence", Ms E 

• The continuing questioning of Atos HCP's professional skills. 

"Many HCP's do not appear to have any knowledge of health 
conditions, long term illness or impairment", Disabled People Against 
Cuts 

• Inaccurate reports being generated at the face-to-face assessment. 

"/ consider the report submitted. . . to only be a selective report and not 
a contemporaneous accurate report of what actually transpired", Mr S 



61 



An Independent Review of the Work Capability Assessment - year two 

73. These concerns should not be ignored. The provision of corroborating 
evidence from a chosen healthcare adviser is particularly important if 
Decision Makers are going to be make balanced and evidence based 
decisions. Therefore, the Review will monitor developments in each of 
these areas during year three. 

74. The Review has, however, also heard anecdotal evidence from several 
sources that on occasions supporting evidence is being withheld from 
Decision Makers and not being submitted until the appeal. It would be 
extremely worrying if this is true, especially if this is being done simply 
to keep the upheld appeal rate high. 

75. It is hoped that fewer negative experiences will be reported overall next 
year as the recommendations from this year and last are fully implemented 
and begin to have a real impact. 

76. The question in the Call for Evidence about the need to present and 
explain the face-to-face assessment in a different way resulted in a real 
mix of views. 

• Some thought the process is mis-understood and therefore needs 
explaining in a different way. 

"Claimants are easily confused as they provide a medical certificate, 
but are told they have not had a diagnostic assessment. This difference 
needs to be much higher profile than at present", DWP Operations 26 
Appeals Officer 



• 



• 



Others thought some tweaks were needed to the language used, but 
otherwise the presentation was about right. 

"Our experience suggests that there often is a mismatch between 
what applicants are expecting the assessment to be like (i.e. more 
of a 'medical') and what it is actually like", Centre for Mental Health, 
Mind, the Royal College of Psychiatrists and the Scottish Association 
for Mental Health 

A further group disagree with the whole policy position underpinning 
the WCA and so thought the answer was not so much about presenting 
it differently, but about redesigning the policy intent. 

"The reason claimants are critical of the assessment is that it. . . fails to 
reflect the true nature of work and the realities of the workplace. Thus, 
there is an urgent need for the DWP to understand the real source of 
our dissatisfaction and anxiety, instead of assuming that we claimants 
misunderstand the purpose of the WCA", Ms R 



26 From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 

62 



An Independent Review of the Work Capability Assessment - year two 

77. It is difficult to reconcile such a diverse range of views. The year one 
Review concluded that the policy intent behind the WCA is the right 
one, and so redesigning the whole assessment would not be practical. 

78. This Review has already reported its own positive experience of the 
implementation of the year one recommendations (see Chapter 2). 
The expectation is that others will start to see these positive changes 
over the coming year. Recommendations in this Review about better 
communications will also help improve things. 

79. As part of their response to the Call for Evidence Citizens Advice Bureau 
submitted survey results analysing the accuracy of 37 reports generated 
during the face-to-face assessment. 

80. The results of this survey are interesting and show that, according to their 
analysis: 

• 43 per cent of reports contained 'severe' errors; 

• 27 per cent of reports contained 'medium' errors; and 

• 30 per cent of reports contained 'few' errors. 

81 .The report also identifies a number of specific criticisms about the reports, 
including: 

• incorrect observations made by HCPs during face-to-face assessments; 

• the style of HCP questioning not giving claimants opportunity to give full 
answers or explain fluctuation; 

• incorrect recording of accounts given by claimant (e.g. on their typical 
day); 

• HCPs making medical judgments 'which they were not in a position to 
decide', sometimes overriding specialists' advice; and 

• lack of consistency in HCP reports, sometimes leading to incorrect points 
being awarded - and not picked up by Decision Makers. 

82. The Call for Evidence asked for robust evidence about the face-to-face 
assessment. Although this survey provided both quantitative and 
qualitative analysis of a number of assessments it must be taken into 
account that the sample size is small compared to the overall number 
of assessments being carried out. 

83. The survey was also conducted between summer 2010 and June 201 1 
and so many of the year one Review's recommendations (see Chapter 2) 
and changes to LiMA (see Chapter 5) are unlikely to have had a real 
impact in that period. 



63 



An Independent Review of the Work Capability Assessment - year two 

84. The Review would welcome a repeat of the survey in 2012 -with an 
increased sample size, if possible - so that trends in accuracy of reports 
can be monitored and further recommendations, if appropriate, can be 
made. 



64 



An Independent Review of the Work Capability Assessment - year two 

Chapter 6: Training 

Background 

1 . In its sixth report of Session 201 0-201 2, the House of Commons Work 
and Pensions Select Committee reported that the Incapacity Benefit 
reassessment process: 

7s not yet properly communicated to claimants, leading to fear and anxiety 
among vulnerable people. " 27 

2. Better communication with and better handling of claimants is one of the 
reasons why appropriate training is needed for those who deal directly with 
the public. This would ensure they have both the technical and softer skills 
necessary to support fully the claimant through the process. 

3. There are four main groups of personnel involved here: 

• Department for Work and Pensions (DWP) Contact Centre staff who 
make initial telephone calls to claimants to explain the process to them; 

• DWP Decision Makers, who make the final decision on benefit 
entitlement and will have more frequent and empathetic contact with 
claimants following the first Review's recommendations; 

• Atos healthcare professionals (HCPs) who conduct the face-to-face 
assessment; and 

• Judges and Medical Members of the First-tier Tribunal who rule on 
appeals if they are made. 

4. The Review believed it was important to gain a better understanding of the 
training provided to these groups as part of this year's programme of work. 

DWP staff 

5. The first Review's recommendations proposed empowering DWP Decision 
Makers. A key training requirement would be to provide these staff 
members with the training and quality assurance packages needed to 
ensure that they can fulfil their new, enhanced role. These measures are 
outlined in Chapter 2, paragraphs 21 to 26 and conclude that positive 
progress has been made in empowering Decision Makers to interact 
more empathetically with claimants. 



27 



http://www.publications.parliament.uk/pa/cm201 01 2/cmselect/cmworpen/1 01 5/1 01 502.htm 

65 



An Independent Review of the Work Capability Assessment - year two 

6. Contact Centre staff have been made aware of the changes, including 
those who are making the follow up telephone call to new claimants whose 
claims are dealt with by Wrexham and Oldham Benefit Delivery Centres. 
There is also a new desk aide to support staff in delivering the key 
messages and if the claimant has a more complex question which they 
are not able to answer they will handover to the Benefit Delivery Centre 
dealing with the claim. 

Atos healthcare professionals 

7. Much of the anger expressed by claimants about the Work Capability 
Assessment (WCA) is aimed at Atos staff and, in particular, those HCPs 
who undertake the face-to-face assessments. 

8. The first year Review talked about recruitment processes for Atos HCPs. 28 
Far more HCPs have been needed to cope with the large increase in 
assessments resulting from Incapacity Benefit reassessment. Details of 
numbers of HCP's in post at the end of May 201 1 are in Chapter 5. It must 
be recognised that these activities, combined with the largely negative 
press they receive, could impact on retention of staff. 

9. Increased turnover of staff could, in turn, lead to increased training 
requirements and a longer time taken for each HCP to reach the required 
competency levels. It is therefore important to improve retention and 
uphold quality. 

10. As part of the year two work, the Review decided that it was important to 
examine the quality of Atos HCP training. Time was spent at an Atos 
Training Centre in Stoke-on-Trent and Atos training materials were 
scrutinised. The new recruits were eager to learn and were engaged in the 
training programme. The trainers also displayed good knowledge about 
the WCA, and were able to stimulate constructive and challenging 
discussions with the recruits. 

11. The scope and depth of the training materials supplied was impressive. 
Nurses and physiotherapists receive a longer training/induction course 
than doctors which makes sense in practical terms. The University of 
Derby have also accredited the nurse training content and this can 
contribute towards their Continuing Professional Development (CPD). 

12. Having undergone the necessary time in training, each trainee has to pass 
all the specified tests before they can enter a period of supervised and 
audited practice. Not until then are they allowed to conduct assessments 
unsupervised. 



28 



Chapter 5, paragraph 1 0, "An Independent Review of the Work Capability Assessment" 



Harrington, 2010. 

66 



An Independent Review of the Work Capability Assessment - year two 

13. Even after their training, the HCPs are regularly audited. More details of 
audit and HCP consistency are in Chapter 5. 

14. All training content is revised annually and training packages have been 
updated to include changes to the legislation and descriptors in March 
2011, the first Independent Review and Incapacity Benefit reassessment. 
DWP approve and sign-off all Atos training materials. 

15. Continuing Professional Development (CPD) programmes are also agreed 
with DWP each year. 

Appeals Judges and Medical Members 

16. Similar requests for details of training packages and quality assurance 
measures were put to the First-tier Tribunal President and the Chief 
Medical Member. 

17. In March 201 1 the Review had an opportunity to observe a training 
exercise for Judges on the subject of the March 201 1 changes to the 
legislation and descriptors used in the WCA. It was a thorough and well 
organised session which energetically engaged the group and revealed 
a real understanding of the WCA and the changes being made to it. 

18. Induction training for Judges and Medical Members is essentially the 
same. There is heavy emphasis on the law, the evaluation of evidence 
and on fact finding. 

19. An initial two and an half day residential training course is followed by an 
evaluation of its effectiveness after six months. Appraisal systems are in 
place on a regional level. Appraisal competences are based on both the 
GMC's Good Medical Practice and the Judicial Studies Board Judicial 
Competencies. 

20. Annual logs are kept of training and educational activity and, after the first 
year appraisal, such procedures are every three years. Refresher training 
courses are available on an annual basis. 

21. In addition, there is a very informative Judicial Information Bulletin with a 
password protected website which is run by Judges and Medical Members 
for themselves. It is thoroughly up-to-date and provides an opportunity for 
Tribunal members to read, comment on and debate issues around the 
WCA and other topics. 

22. First-tier Tribunal training is accredited by the Law Society and the Bar 
Council and attracts CPD for the legally qualified panel members. Medical 
Members receive a certificate of attendance. 



67 



An Independent Review of the Work Capability Assessment - year two 

Conclusions 

23. From an extensive review of training materials, answers to a number of 
additional questions to get further information and first hand evidence of 
training in practice, the Review believes that both Atos and the First-tier 
Tribunal provide good and comprehensive training opportunities for their 
staff. 

24. Refresher training courses seem relevant and up to date and appraisal 
procedures appear to be sound and thorough. 

25. For Atos HCPs the training is focussed on disability medicine and using 
the tools necessary to undertake the face-to-face assessment, including 
the LiMA computer system. 

26. For the Medical Members of the First-tier Tribunal, their training is largely 
geared to improving their knowledge of the law as their responsibility is to 
assess accurately each appeal based on facts of law. 

27. From 2012 medically qualified practitioners in this country will have to sign 
up to a Revalidation process set out by the General Medical Council 
(GMC) in order to determine whether they are fit to continue to hold a 
license to practice. This will occur every five years. All the medical 
Colleges and Faculties have annual accreditation/appraisal schemes 

in place for their members which should ensure that Revalidation every 
five years with the GMC is not a problem. 

28. It is unclear to the Review which accreditation/appraisal schemes are the 
most suitable for the medically qualified personnel employed by Atos and 
the First-tier Tribunal. 

29. It is also worth noting that practitioners who merely wish to remain 
registered with the GMC can still practice in certain contexts. In 2009 
Ministry of Justice Ministers accepted that whilst Tribunal Medical 
Members need to be registered with the GMC and therefore conforming to 
the principles laid down in Good Medical Practice, they did not need to be 
licensed and could decide to remain registered only. The qualifications 
order for members of the First-tier Tribunal was amended accordingly. 

30. The practical application of training is as important as the training itself. 
The quality of outcomes will help determine whether or not the training 
is being used to ensure the WCA works as well as it should. 



68 



An Independent Review of the Work Capability Assessment - year two 

Recommendations 

After reviewing the training materials used in the WCA I recommend that: 

DWP should continue to monitor the quality and appropriateness of 
DWP Operations and Atos training. 

31 .The Review was satisfied that, in 201 1 , both Atos and the First-tier 
Tribunal had delivered relevant and up to date training for their staff 
involved in the WCA. It is important that the quality of the training provided 
to Atos HCPs is monitored as any subsequent changes to the WCA are 
made. 

32. The Review has also seen first hand the new training for DWP Decision 
Makers which has been implemented as a result of the year one 
recommendations. It is important that DWP monitor the quality and impact 
of this training as well on an ongoing basis given the key role of Decision 
Makers in the WCA process. 

33. Similar commitments from the First-tier Tribunal about their training would 
also be helpful, but this is arguably outside the remit of the Review. 

Where appropriate, there should be sharing of knowledge and 
training between the various groups involved in the WCA. 

34. All of the training materials seen this year have been of high quality. 
However, the Review understands that there is very little (if any) sharing 
of knowledge about, and interpretation of, the WCA and how it is applied. 

35. Greater join up between the various bodies' training would mean a better 
shared understanding of what each part of the process is trying to achieve. 
This could involve a mutual sharing of the training materials used by each 
body to facilitate greater understanding of how and why each does things 
the way it does; or a more regular and formal process of discussing 
training in an open forum. 

36. The First-tier Tribunal President has informed the Review that any 

consideration of judicial training is outside the remit of the Review. Whilst 
this concern is duly noted, involving them in this sharing of knowledge 
would have considerable benefits to the overall WCA process and the 
Review would hope that consideration is given to them engaging with 
DWP Operations and Atos. 

DWP should closely monitor the recruitment, and retention, of Atos 
healthcare professionals in year three. 



69 



An Independent Review of the Work Capability Assessment - year two 

37. The increased workload caused by Incapacity Benefit migration will, 

inevitably, put strains on Atos. Given that the LiMA system seems to work 
reasonably well if the HCPs are able to use it properly (see Chapter 5), 
the onus for the delivery of sound, accurate and effective assessments 
which the Decision Makers can use to make reasoned and evidence 
based decisions on rests heavily on Atos. To do this they need to 
maintain a body of first class HCP's. 

38. A high turnover of staff will place undue demands on the training 
programme that Atos have put in place, which in turn could have 
a negative impact on the assessment process as a whole. 



70 



An Independent Review of the Work Capability Assessment - year two 

Chapter 7: Other issues 

People who are found Fit for Work but are unable to 
claim Jobseeker's Allowance (JSA): year one 
recommendation 

1 . In year two, the Review should examine what happens to people who are 
found Fit for Work but are unable to claim Jobseeker's Allowance (JSA). 

Background 

2. Analysis of this problem suggests that there are two groups of people who 
potentially fall into this category: 

• People who, although having been found Fit for Work in their Work 
Capability Assessment (WCA), still feel that they are unable to work 
due to the impact of their health condition or disability or whose 
Personal Adviser in Department for Work and Pensions (DWP) 
Operations 29 feels are unable to work for the same reason; and 

• People who are still in employment but who are found Fit for Work 
and so would have to leave employment in order to fulfil conditionality 
under JSA. 

Analysis of the problem 

DWP Operations communications 

3. Anecdotal evidence has shown that a proportion of claimants found Fit for 
Work in their WCA still feel that they are unable to work due to their health 
condition or disability. This may be exacerbated by Personal Advisers in 
DWP Operations who tell claimants they cannot understand how the Fit for 
Work decision was reached. 

4. The Review has found that the problem may be that the claimant has not 
had a proper explanation of the decision to find them Fit for Work or the 
subsequent help and support available to them on JSA or the Work 
Programme. Lack of clarity of the reason for a Fit for Work decision 
despite ill-health or disability and failure to explain what happens next 
could lead to appealing the decision or making a new claim for ESA 

and a subsequent cycling through the benefits system. 



29 From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 

71 



An Independent Review of the Work Capability Assessment - year two 

5. DWP Operations must ensure that a claimant is clear on what their options 
are once a decision has been made on their entitlement to ESA. The 
claimant must also receive consistently clear messages from DWP 
Operations - whether that is from the Contact Centre, a Personal Adviser 
or a Decision Maker. The way in which DWP Operations communicates 
with claimants and internally is essential to ensuring that claimants are 
not caught in a cycle of claiming, reclaiming and appealing ESA. 
Communications between Decision Makers and Personal Advisers in 
DWP Operations appear to be particularly important if a 'silo' mentality is 
to be avoided with Personal Advisers backing up positive messages about 
a possible return to work. 

6. Implementation of the first Review's recommendations has led to more 
support for the claimant during the course of their benefit claim (see 
Chapter 2). This will help the claimant better understand what is 
happening to them and why. But it would also be helpful for DWP 
Operations to take additional steps to ensure that each area of the claim 
process communicates with each other regularly, clearly and consistently. 

Claimants in employment and found Fit for Work 

7. There are also a group of people who claim ESA that have a contract 
of employment, but are temporarily incapacitated and so unable to do 
their job. 

8. Most will have a 'fit note' from their GP that says they are currently unfit for 
their job. If this is the case then reasonable adjustments by the employer 
should be the first option (e.g. revised duties or reducing working hours 

to fit around the temporary circumstances), working alongside a DWP 
Operations Disability Employment Adviser if appropriate. 

9. However, it may be necessary for some of these people to make a short- 
term claim for ESA, for example if their Statutory Sick Pay has expired. 

10. As the WCA assesses functionality for any work these people may be 
found Fit for Work but find that they are unfit to return to their normal work 
duties. They cannot claim ESA because they have been found functionally 
fit to work but are unable to claim JSA because their employment status 
will negate them from claiming JSA. 

1 1 .To fix this anomaly would require changes to JSA legislation which is out 
of the scope of this Review. 



72 



An Independent Review of the Work Capability Assessment - year two 

Universal Credit 

12. A longer-term solution to this problem will be provided with the introduction 
of Universal Credit, which will be a single income-related payment 
reflecting the personal circumstances of the claimant whether they are 

in or out of work. The Review understands that under Universal Credit: 

• As long as an individual meets the basic entitlement conditions, they 
will be entitled to Universal Credit regardless of their employment 
status. The amount of Universal Credit payable will depend on the 
person's needs and circumstances, and will increase or taper off in 
response to fluctuations in their earnings. There will be no need to 
carry forward existing entitlement rules around permitted work as there 
will be a new system of earnings disregards and a single taper. Nor will 
there be the same distinction between in and out of work claimants 
(such as the definitions which currently restrict eligibility for JSA); and 

• The application of conditionality will be more flexible than now, with 
requirements tailored to the capability and circumstances of individuals 
rather than dictated by which benefit they claim. So where a person is 
expected to meet work-related requirements, these will be set through 
discussion with a Personal Adviser, taking into account the claimant's 
health and ensuring that they are compatible with any existing contract 
of employment. 

Recommendations 

Taking all the evidence into account, I recommend that: 

DWP Operations should improve internal communications to ensure 
that each part of the claims process and Personal Advisers have a 
broad understanding of the policy intent of the WCA, what a Fit for 
Work decision means for a claimant and the support available to 
them. 

DWP Operations should continue to monitor the impact of the year 
one recommendations, particularly the additional 'touch points' with 
claimants, to better understand whether messages about the support 
available on Jobseeker's Allowance are fully understood by 
claimants. 

13. If everyone in the claims process does not understand, even in broad 
terms, what it is trying to do and why there is a risk that communications 
will be piecemeal then claimants will get contradictory messages from 
different people. This undermines the whole process and risks derailing 
the positive efforts to try and get people who are able to work into 
employment. 



73 



An Independent Review of the Work Capability Assessment - year two 

14. Similarly it is important to explain fully the help and support available on 
JSA to claimants found Fit for Work. Currently not reaching the ESA points 
threshold is seen by many as 'failing' the assessment when in fact being 
able to work will be much more positive for many people. 

15. More transparent messages for claimants - especially on what they are 
being assessed on and what the descriptors actually mean in practice - 
could also reduce feelings of embitterment and being assessed against 
opaque criteria. 

DWP should ensure that Universal Credit considers the risks of 
applying conditionality to those claimants who are currently 
employed. 

16. Whilst Universal Credit is beyond the scope of this Review it is clearly in 
the Review's interest to ensure people making short-term benefit claim 
because of a genuine need are protected in the system. 

17. It appears that Universal Credit will offer a pragmatic solution to a problem 
within the current system. The Review looks forward to seeing how this 
works in practice once Universal Credit is implemented. 

Complex problems and chaotic lifestyles 

18. Several people, in either Call for Evidence responses or meetings, have 
noted that people with complex problems may face particular challenges 
in the WCA. This could include people with addictions (including drugs 
and alcohol) or people who are homeless. These problems may be 
exacerbated by co-morbidity and underlying, potentially undiagnosed, 
conditions. 

19. Whilst the WCA rightly focuses on functional capability rather than 
diagnosis, the Review believed it was important to explore some of these 
issues in more detail to ensure that people were not being unfairly treated. 
Problem drug users were the focus of this, although it is likely that the 
findings will apply equally to other conditions. 

Problem drug users 

20. Several drugs charities, particularly the UK Drug Policy Commission 
(UKDPC), put forward the case that problem drug users (PDU) had 
particular difficulties in the WCA above and beyond claimants with other 
mental health conditions. Evidence suggests that these PDUs are more 
likely to be stigmatised in terms of employment and that they required a 
longer and more intensive rehabilitation on the way to full employment. 

21.Atos and DWP Operations were approached to see what, if any, measures 
were in place to deal with PDUs as a special case within the WCA 
process. 



74 



An Independent Review of the Work Capability Assessment - year two 

22. The responses indicated that whilst Atos do not have specific procedures 
for claimants with addictions they are treated as for mental health 
conditions and the new Mental Function Champions 30 would assist in 
their assessments. 

23.DWP Operations, for its part, recognised residential rehabilitation as 
a special case after the implementation of the DWP internal review in 
March 201 1 . This means that anyone in residential rehabilitation is now 
treated as having limited capability for work for the purposes of ESA. 

24. DWP Operations can also call on the assistance and expertise of Drug 
Champions where available at a local level and also cover drug use in 
their general skills training. Personal Advisers should always consider 
flexibilities within a Jobseeker's Agreement to take account of a drug 
addiction and existing treatment commitments, however a jobseeker 
must still be available for and actively seeking work. 

25. There is also continuing work to implement the Government's 2010 Drug 
Strategy which will extend the Personal Adviser options for conditionality 
for individuals in structured recovery activity: 

"We will offer claimants who are dependent on drugs or alcohol a choice 
between rigorous enforcement of the normal conditions and sanctions 
where they are not engaged in structured recovery activity, or 
appropriately tailored conditionality for those that are. Over the longer 
term, we will explore building appropriate incentives into the universal 
credit system to encourage and reward treatment take-up. ,l31 

26. The UKDPC also pointed out that residential rehabilitation only accounts 
for around 2 per cent of all PDU's treatment and, as a group, these 
claimants need longer and more detailed assistance before they are ready 
for full time employment. 

27. There appears to be a case, therefore, for Atos and DWP Operations to 
have access to additional advice in order to enhance their assistance to 
PDUs in the WCA and beyond. 



30 Chapter 5, paragraphs 48-49, "An Independent Review of the Work Capability 
Assessment", Harrington, 2010. 

31 Page 23, http://www.homeoffice.gov.uk/publications/alcohol-drugs/drugs/drug- 
strategy/drug-strategy-2010?view=Binary 

75 



An Independent Review of the Work Capability Assessment - year two 

Recommendations 

Based on the evidence provided to the Review, I recommend that: 

DWP Operations should consider seeking, and using, advice and 
guidance from the UK Drug Policy Commission and other relevant 
experts in order to improve and enhance the knowledge and 
capability of Decision Makers and Personal Advisers in managing 
these cases (see also Chapter 3). 

Similar advice should be sought by Atos for their Mental Function 
Champions and the UK Drug Policy Commission and other relevant 
experts could be involved in updating the relevant sections of the 
Atos Guidance Manual for their healthcare professionals (see also 
Chapter 3). 

28. Whilst a strong argument cannot be made for making PDUs a special case 
in the WCA (indeed the UKDPC recognise the value of employment to 
recovery) there is a need to ensure that both Atos and DWP Operations 
staff have the most up-to-date knowledge available to them about the 
challenges PDUs may face in finding and sustaining employment. 

Communication problems, including dyslexia 

29. In June 201 1 the Review was approached by Lord Addington. He put 
forward the case that people with dyslexia may not be well prepared for 
the WCA and that they may not be getting correct and useful advice 
throughout the process, particularly at initial contact. 

30. With 10 per cent of the population having some form of problem with 
literacy and the ESA50 being a key part of the ESA claim the Review 
agreed that this was something worth exploring in more detail. 

31 . It is likely that these problems will apply equally to people with general 
communication problems - which may result from a mental health 
condition or a learning disability - and not just to people with literacy 
problems. 

32. DWP Operations have informed the Review that any claimant, not just 
someone with dyslexia, can request help to complete their ESA50. This 
can take the form of: 

• Someone from DWP Operations phoning the claimant back and going 
through the ESA50 question by question to transcribe their answers; 

• A face-to-face interview at a Jobcentre Plus office where the same 
transcribing service is available; 

• An audio version of the ESA50, which people listen to so they are 
aware of the questions before filling in the form themselves or asking 
for help from a friend or relative or the transcribing services provided 
by DWP Operations; 



76 



An Independent Review of the Work Capability Assessment - year two 

• An online version of the ESA50, which is compatible with accessibility 
programmes available; and/or 

• Claimants asking a friend or relative to help them complete the form. 

33. This appears to be a comprehensive range of possible ways of completing 
the form for people with dyslexia or other literacy problems. Taken in 
combination with the fact that the face-to-face assessment will still go 
ahead if there is no completed ESA50 and a mental or behavioural 
condition is recorded on DWP Operation's systems (i.e. a claim for ESA 
will usually only be stopped if the claimant requests that it is - see Chapter 
4 for more details), this appears to suggest that processes are robust. 

34. Although the number of people who apply for ESA with dyslexia as their 
primary condition is small (less than ten in 2010/11), the Review's biggest 
concern with dyslexia and other literacy problems is people who do not 
recognise that they have a problem and so may disadvantage themselves 
in a claim through an inaccurate or incomplete ESA50. This is also a 
potential problem for mental health conditions and learning disabilities. 

35. This problem will apply to both the ESA50 and the face-to-face 

assessment. There is no easy way of getting around this, but the routine 
collection of evidence from a chosen healthcare adviser should help the 
application and Decision Making process. The Review has already noted 
the positive moves by DWP Operations to collect corroborating evidence 
from a chosen healthcare adviser in Chapter 2, but recognises that more 
work is needed before this process works perfectly. 

Northern Ireland Independent Review 

Year one review 

36. Early in 201 1 , Professor Harrington was approached by the Department 
for Social Development in Northern Ireland, requesting a similar 
independent assessment of the WCA as it operated in Northern Ireland 
as was carried out in Great Britain in 201 0. 32 

37. Following discussions, it was agreed that the most cost efficient way of 
dealing with the request for a review was for the Department to identify 
the Northern Ireland specific issues. It was also agreed that they should 
indicate whether the year one recommendations could be implemented 
in Northern Ireland and where they were not applicable or alternative 
arrangements were already in place. 

38. The supply of this information led to additional requests from Professor 
Harrington for expansion and clarification and these responses were 
delivered speedily. 



32 http://www.dsdni.gov.uk/wca-review.pdf 



77 



An Independent Review of the Work Capability Assessment - year two 

39. A final assessment from Northern Ireland was received in August 201 1 . 
Professor Harrington was able to approve their report - particularly some 
interesting observations about the Decision Making process in Northern 
Ireland - and a final version was submitted to the Northern Ireland 
Assembly in September 201 1 . 

40. Subsequent activities of the Great Britain Review have been extended to 
Northern Ireland and a Call for Evidence mirroring the Great Britain one 
was issued in Northern Ireland in September 2011. The responses have 
since been collated in Belfast and sent on to the Review for consideration 
in due course. 

Update since the year one review 

41 .The Department for Social Development have now provided Professor 
Harrington with an update to the position in Northern Ireland since the 
publication of the first report in September. It is encouraging to already 
see further progress in the implementation of the Great Britain Review's 
recommendations. 

42. Enhancements have been made to the Employment and Support 
Allowance claimant journey, and further pilot exercises have been 
developed to commence in the coming months. 

43. Professor Harrington has strongly advocated the use of free text in 
assessment reports and, in line with Department for Work and Pensions, 
the Department for Social Development has introduced the use of a 
personalised summary statement since Atos began carrying out face-to- 
face assessments in June 201 1 . The feedback from Decision Makers 
about this has been positive. 

44. The Department has also been proactive in putting a detailed proposal to 
Atos for the provision of Mental Function Champions for Northern Ireland. 

45. Any changes to the LiMA system resulting from the Great Britain Review 
will be taken forward in Northern Ireland as a matter of course through 
existing processes. 

46. A research proposal is currently being developed to examine borderline 
cases in ESA decision making in Northern Ireland; whilst a piece of 
research is being commissioned to examine the destinations and 
outcomes of claimants going through the WCA process. 

47. In addition, it is intended that Northern Ireland will be fully integrated 
into any further work on the descriptors. 



78 



An Independent Review of the Work Capability Assessment - year two 

48. One further significant development has been the appointment of a Health 
Assessment Advisor in August 201 1 , to: 

• provide medical governance to Atos; 

• support the implementation of the Harrington recommendations; and 

• be responsible for ensuring the quality of services provided by Atos, 
including their audit processes, the standard of training and training 
material provided to healthcare professionals, quality assurance of 
medical guidance and the approval of all appointed healthcare 
professionals. 

49. As was the case in response to the first independent review of the WCA, 
Professor Harrington now recommends that the Department for Social 
Development examines the recommendations included in the Great Britain 
year two Review and considers their application within the Northern 
Ireland context. 

50. Professor Harrington looks forward to receiving a response from the 
Department for Social Development in due course, and welcomes the 
full alignment of Northern Ireland and Great Britain work streams for the 
period of the third review. 



79 



An Independent Review of the Work Capability Assessment - year two 

Conclusion 

1 . The first independent review of the Work Capability Assessment (WCA) 
concluded that the assessment is the right concept. This remains the case. 

2. However, the first review also concluded that modifications at all stages of 
the assessment process were required to make it a fairer, more effective 
and more humane process. In this respect positive progress has been 
made over the last 12 months, and the Review expects this progress to 
be consolidated and built upon in the next year. 

3. The reassessment of Incapacity Benefit claimants for eligibility for 
Employment and Support Allowance (ESA) as well as the number of 
people making a new claim for ESA will, understandably, place 
considerable demands on every part of the WCA process. But it also 
serves to emphasise the need for the right decision about a claimants' 
eligibility for ESA to be made first time. 

4. This means that everyone involved in the process (from Contact Centre 
and Benefit Delivery Centre staff, to Atos, to individuals making a claim) 
have a responsibility to ensure that accurate and reliable information is 
available and is communicated at each stage. 

5. There is an obvious need to support fully people who are unable to work 
through ill health or a disability. However, there is also a need to move 
away from concepts of 'passing' or 'failing' a WCA which are unhelpful 
and often cloud the evidence linking health and work. 

6. A fair and effective WCA will help in this respect, as well as providing 
a more cost effective system than is currently in operation. 



81 



An Independent Review of the Work Capability Assessment - year two 

Annex A: List of recommendations 



Implementation of the year one recommendations 




1 


Implementation of the Review's recommendations should be monitored 
over time and on a regular basis, including focus on: 

• Percentage of claimants failing to return the initial ESA50 
questionnaire; 

• Percentage of claimants failing to attend the face-to-face 
assessment; 

• Percentage of decisions meeting criteria in the Decision Making 
Quality Assessment Framework; 

• Percentage of reconsiderations received; 

• Percentage of decisions changed following reconsideration; 

• Percentage of appeals received; and 

• Percentage of appeals upheld. 


2 


Unannounced visits to both Benefits Delivery Centres and Atos 
Assessment Centres should be carried out during the year three Review. 


Descriptors 


3 


A 'gold standard' review be carried out, beginning in early 2012. Future 
decisions about the mental, intellectual and cognitive descriptors should 
be based on the findings of this review. 


4 


DWP should consider working with relevant representative groups and 
their clinical advisers to: 

• Update the handbook and guidance used by Atos healthcare 
professionals; and 

• Produce practical guidance for Decision Makers. 


5 


This 'bottom up' model - involving a wide range of experts as well as 
DWP - should also be adopted in any future changes to the WCA 
descriptors, where appropriate. 



83 



An Independent Review of the Work Capability Assessment - year two 



Work on the specific wording of the sensory descriptors and an additional 
descriptor which addresses the impact of generalised pain and/or fatigue 
should be considered early on in the year three Review. 



As and when changes to the descriptors are made, DWP and other 
relevant experts should monitor the impact of these changes to ensure 
both that they are working and that they are not causing any unintended 
consequences. 



8 DWP consider ways of sharing outcomes of the WCA with Work 
Programme providers to ensure a smoother claimant journey. 

Research 

'Borderline' cases 



DWP undertake regular audit of Decision Maker performance. 



10 



In year three, further research is undertaken to examine in more detail 
what happens to people found Fit for Work and people placed in the 
Work Related Activity (including Work Programme outcomes) and 
Support Groups, and the factors influencing these outcomes. 



Atos Healthcare 



Logic Integrated Medical Assessment (LiMA) - the Atos IT system 



11 



These changes [to LiMA, based on comments from the stakeholder 
seminars] should be adopted, and that further changes to LiMA are 
considered as and when they are raised. 



12 



Atos and DWP monitor and audit the use of free text within LiMA to 
ensure a consistently high standard of accurate reports. 



13 



If needed, Atos healthcare professionals are provided with the relevant 
IT training - especially typing - to enable them to use the LiMA system 
intelligently and ensure that the quality of the face-to-face assessment 
does not suffer. 



84 



An Independent Review of the Work Capability Assessment - year two 



Healthcare professional consistency 



14 



Given the importance of the quality of assessments (especially with 
Incapacity Benefit reassessment fully underway) DWP should consider 
tightening the target for C-grade reports. 



15 



To improve the transparency of the face-to-face assessment, data on 
Atos performance and quality should be regularly published. 



Training 



16 



DWP should continue to monitor the quality and appropriateness of DWP 
Operations and Atos training. 



17 



Where appropriate, there should be sharing of knowledge and training 
between the various groups involved in the WCA. 



18 



DWP should closely monitor the recruitment, and retention, of Atos 
healthcare professionals in year three. 



Other issues 



Fit for Work but unable to claim Jobseeker's Allowance (JSA) 



19 



DWP Operations should improve internal communications to ensure that 
each part of the claims process and Personal Advisers have a broad 
understanding of the policy intent of the WCA, what a Fit for Work 
decision means for a claimant and the support available to them. 



20 



DWP Operations should continue to monitor the impact of the year one 
recommendations, particularly the additional 'touch points' with claimants, 
to better understand whether messages about the support available on 
Jobseeker's Allowance are fully understood by claimants. 



21 



DWP should ensure that Universal Credit considers the risks of applying 
conditionality to those claimants who are currently employed. 



85 



An Independent Review of the Work Capability Assessment - year two 



Problem drug users 



22 



DWP Operations should consider seeking, and using, advice and 
guidance from the UK Drug Policy Commission and other relevant 
experts in order to improve and enhance the knowledge and capability 
of Decision Makers and Personal Advisers in managing these cases 
(see also Chapter 3). 



23 



Similar advice should be sought by Atos for their Mental Function 
Champions and the UK Drug Policy Commission and other relevant 
experts could be involved in updating the relevant sections of the Atos 
Guidance Manual for their healthcare professionals (see also Chapter 3). 



86 



An Independent Review of the Work Capability Assessment - year two 

Annex B: Acknowledgements 

1 . In the first Independent Review of the Work Capability Assessment 
(WCA), I set out an extensive list of recommendations to improve the 
fairness and effectiveness of the assessment. The Government accepted 
all of them and the Department of Work and Pensions (DWP) rapidly set 
about the task of turning those proposals into practice. 

2. Staff at all levels in DWP Operations 33 have ensured that real action 
followed policy. It has been a pleasure to work with such dedicated and 
committed people within the Department. 

3. My Scrutiny Group of Dr Olivia Carlton, Paul Farmer and Neil Lennox were 
superbly led by Professor David Haslam. They have been a source of 
immense help and support throughout this years work. I am indebted 

to them. 

4. A number of the major charities and patient support groups have been 
actively engaged with me in providing proposals for revising a number 
of the descriptors used in the assessment. This work has progressed 
efficiently and swiftly. I thank the charities for their forbearance when 
some areas of their proposals have progressed slower than I would have 
wished. 

5. The team at DWP has, this year, been smaller than last year but the work 
has been just as taxing. Mark Wilson and Philip Cooper have done a great 
job in helping me to produce this second Review. Throughout the year, 
Mark has been an invaluable source of advice, help and wisdom - not 
least in guiding me through the workings of a large Government 
Department. I thank Phil and Mark most sincerely. 

6. I also would like to thank the organisations and individuals (over 425 in 
total) who responded to the Call for Evidence, or attended my seminars on 
aspects of the WCA, or who were happy to allow me to take up their time 
with questions and yet more questions. Particularly: 

Lord Addington; Professor Dame Carol Black; Dr Steve Boorman; 
Dr Laura Crawford; Anna Deignan; Dr David Henderson-Slater; 
Dr Josanne Holloway; Dr Paul Litchfield; The Countess of Mar; 
Dr Ed McDermott; Baroness Molly Meacher; Professor Robert Moots; 
Dr Maurice Murphy; Donna Pereira; Rachel Perkins; Dr Jane Rayner; 
Baroness Ruth Runciman; Dr Helen Sapper; Liz Sayce; 
Professor Tom Sensky; Richard Thomas; Sir Richard Tilt. 



33 From October 201 1 the formal agency status of Jobcentre Plus ceased to exist. For clarity 
and consistency throughout this document the work of Jobcentre Plus before October 201 1 
and anything after then are both referred to as DWP Operations. 

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